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COPYRIGHT DEPCSm 



THE 

PREVENTION AND 

TREATMENT OF 

INFECTIONS 



BY 

OLIVER T. OSBORNE. A.M.. M.D. 

Professor of Therapeutics and formerly Professor of Clinical Medicine in 

Yale Medical School; Member of the Council on 

Pharmacy and Chemistry, etc. 

NEW HAVEN, CONN. 



THE JOURNAL of the AMERICAN MEDICAL ASSOCL\TION 
Five Hundred Thirty-Five North Dearborn Street, Chicago 



-^VroA 



Copyright, 1915 
By the American Medical Association 



MAY 20 lSi5 

O)CU4010^1 



PREFACE 



During the publication in The Journal of the Ameri- 
can Medical Association of the series of articles enti- 
tled "Prevention Greater Than Cure," frequent sug- 
gestions were made for their publication in book form. 
In response to these suggestions, they are now repro- 
duced in this form. The influence of the ordinary 
factors of life on health, the modern methods for the 
prevention of disease and the treatment of the com- 
moner disorders, especially those affecting the growing 
child, are the subjects considered. The aim has been 
to make this a practical handbook for those interested 
in the care of the child — the physician, the teacher, 
the hygienist, the school inspector. 



CONTENTS 



PAGE 

Some Common Factors in Immunity 1 

Vaccine Prevention and Vaccine Therapy 40 

The School Question 52 

The Common Infectious Diseases 91 

Diseases of the Respiratory Tract 92 

Hookworm Disease 118 

Whooping-Cough 124 

Mumps 137 

Diphtheria 142 

Septic Sore Throat 169 

Measles 171 

German Measles (Rotheln, Rubella) 183 

Chicken-Pox ; Varicella 185 

Scarlet Fever 188 

Cerebrospinal Fever 209 

Acute Anterior Poliomyelitis (Infantile Paralysis) 222 

Index 235 



CHAPTER I 



SOME COMMON FACTORS IN IMMUNITY 



LIFE PROBLEMS 

The "survival of the fittest" begins with the germ 
of reproduction, goes through embryonic Ufe, through 
parturition, through infant life, through childhood, 
and presumably should be considered as ultimately 
satisfied at 20 years of age, but it is not perfectly 
satisfied until another individual emanating from this 
"fit" individual of 20 years or more has also reached 
the age of 20. Such, theoretically, may be considered 
the "survival of the fittest." 

It is the object of this series of articles to cause 
medical men to review the knowledge already acquired 
of the means and methods of causing more "fit" 
to be born, and more "fit" to survive and have their 
health unimpaired by preventable disease. 

To show how lavishly nature provides at the start 
for the survival of the fittest, it should be noted that 
each human male having normal sexual health and 
living until the age of 60 is said to produce more than 
300 billions of spermatozoa, while the ovaries of the 
human female are said at puberty to contain about 
30,000 eggs. This is not to suggest that the world 
would be happier with an enormous increase of indi- 
viduals, but it will be happier, and there will be less 
poverty, if there are more normal individuals and 
fewer abnormal ones. The economic value of wars 
and plagues need not be discussed, but it should be 
remembered that the strongest men (the most "fit") 
are the ones who die in battle, and that pestilences 
destroy the "fit" as well as the "unfit." 



2 SLEEP 

The great sterilizer of men and women, especially 
the latter, is gonorrhea; the great abortionist is 
syphilis. And again, these diseases are likely to be 
acquired by the "fit" among our men, and, unfortu- 
nately, often innocently acquired by the "fit" among 
our women. Therefore, war, pestilence, gonorrhea 
and syphilis entail an inferior progeny, and hence 
economically and socially are deplorable. 

Most infectious diseases leave the individual less 
"fit," although after surviving an acute onslaught of 
some one or more of these diseases he may acquire 
an immunity to the germs and to infections in general, 
and he may even, as years go by, transmit more or 
less of such immunity to his offspring. Or, on the 
other hand, he may transmit a susceptibility to cer- 
tain germs to his offspring. Most severe attacks, 
and even mild attacks, of infection leave permanent 
marks on the individual, even though he survive. 
Hence the great purposes of medical men, to-day, 
are: (1) to prevent disease; (2) to produce anti- 
vaccines that will protect or cause immunity to a 
disease without so disturbing the organism as to cause 
permanent lesions or damage to tissues; (3) if an 
antivaccine cannot be produced, to discover an anti- 
toxin that will rapidly inhibit the infection when it 
occurs; (4) to advance physiology and chemistry so 
that the needs of a defective organ may be supplied 
by the organic extract or chemical stimulant that it 
needs; (5) to disseminate the knowledge now 
acquired as to proper hygiene, proper diet and food 
values, and the methods of acquiring not only infec- 
tious diseases but also chronic organic diseases and 
thus to stave off preventable diseases and postpone 
diseases due to age. 

SLEEP 

This is a necessary and not sufficiently discussed 
part of our daily life. About one-third of each day 
of an adult's life should be spent in restful, natural 
sleep. Some individuals require more than others. 



SLEEP 3 

but eight hours is the average requirement. Loss of 
consciousness, not syncope, not coma, not stupefac- 
tion by drugs, constitute normal sleep. People who 
are not mentally alert, who are heavy and stupid or 
who are mentally insufficient sleep easily. This is 
true of cretins, of those of low mentality, of the 
absolutely illiterate (those who have little to think 
about), and of the very obese (in these cases drowsi* 
ness may be due to the amount of blood needed and 
circulated in the fat). Individuals who are anemic 
are likely to be sleepy and require more sleep. Chil- 
dren, young children especially, require much more 
sleep than adults, as their active brains become more 
readily fatigued. 

The conditions favoring normal sleep are probably 
(1) fatigue products circulating in the brain or caus- 
ing vasodilatation of the abdominal and peripheral 
circulation ; (2) anemia of the brain more or less rela- 
tive to that during consciousness, and (3) diminished 
cerebral reflex stimulation from external stimuli due 
to the dulling influence of fatigue products on reflex 
cerebral or spinal irritability, or it may be that such 
products circulating in the blood dull the senses and 
the peripheral sense nerves, or both. 

During sleep the pulse is slowed and the brain con- 
tains less blood, while the other organs of the body 
contain more blood. The blood-pressure is lowered. 
The eliminative glands are more active, notably the 
sweat glands and the kidneys, but the secreting glands 
are diminished in activity. During sleep cellular repair 
takes place, final products of metabolism are formed 
and excretion is promoted. 

Normal sleep cannot be produced by hypnotic drugs, 
although unconsciousness may be caused and the 
patient made to sleep. Under the action of hypnotics 
one or many organs do not functionate and cannot 
normally act, and the resultant sleep is inferior to 
natural sleep. Perhaps the most normal hypnotic is 



4 WATER 

that which causes sleep by lowering the blood-pressure 
and causing anemia of the brain. 

High blood-pressure, hysteria, etc., are causes of 
sleeplessness, and in these and many other conditions 
sleep must be brought about by physical methods, if 
possible; or it may be necessary to have recourse to 
drugs. Absolute insomnia is dangerous and must be 
stopped, but the continued use of hypnotic drugs 
invites only disaster, though the temporary use of such 
drugs may soon promote normal sleep and may actu- 
ally save life. In fact, not enough thought is given 
by physicians to the amount of sleep that their patients 
obtain. Regulation of the sleep should be aimed at by 
every physician in every case requiring his care. 

On the other hand, too much sleep is disastrous; 
the individual's brain becomes sluggish and incompe- 
tent, overpassive congestion of the abdominal organs 
takes place, sluggish metabolism occurs, constipation, 
kidney disturbances and a weakened circulation are 
the results. Patients who complain of being, or whom 
questioning shows to be, abnormally sleepy are path- 
ologic and need medical advice. Overeating, alcohol, 
cerebral plethora, obesity, failing circulation and sub- 
thyroid secretion may all be causes of sleepiness. The 
cause being discovered, the treatment is self-evident. 

Among the most frequent causes of insomnia are 
peripheral irritations, mental anxiety and hyperthyroid 
secretion. 

WATER 

The amount of water that should be taken is impor- 
tant, and quite generally is neglected by physicians in 
treating their patients. It is not a physiologic crime 
or a sign of a beginning pathologic condition to arise 
once at night to urinate (insurance examination blanks 
to the contrary notwithstanding), in cases m which 
the patient drinks a glass or two of water before retir- 
ing, which is not an infrequent habit. If the emunc- 
tories are to properly work during sleep, water is 
needed, and it should not be withheld. There is no 



WATER 5 

intention in the above to minimize the importance of 
the symptom of arising several times at night to uri- 
nate as an indication of high blood-pressure and kid- 
ney, bladder or nervous irritability. 

Water in plenty is an essential part of the diet at 
all times, and especially should goodly amounts of it 
be ordered in most conditions that require medical 
treatment. It is absurd to allow the "water cures" to 
do all the ordering of this simple sanitary flushing 
commodity. 

Before all operations, if there is time (that is, if it 
is not an emergency case), large amounts of water as 
well as plenty of starchy (carbohydrate) food should 
be given. After an operation the giving of a colon 
injection of from one pint to one quart of physiologic 
saline solution is good practice, and if the patient after 
operation receives such injection he will have less 
toxemia, less vomiting, better acting skin and kidneys, 
less headache and more sleep. 

On the other hand, let us decry the thoughtless 
ordering of large amounts of water, or lithiated or 
other fool waters, for patients who may be gouty and 
have defective kidneys, but who also have impaired 
circulation. An albuminuria from heart or kidney 
defect rarely calls for large amounts of water. Exces- 
sive amounts will weaken the circulation and cause 
congestion of the kidneys and dropsies. 

The best time for taking extra water, that is, besides 
the normal goodly amount with meals, is three hours 
after eating. A considerable amount of water taken 
with a meal does not diminish or slow digestion; 
neither does a large amount of water taken between 
meals diminish the hydrochloric acid of the stomach. 
Hence water increases and does not inhibit gastric effi- 
ciency, and it promotes intestinal health. In cases of 
gastroptosis or gastric dilatation, large amounts of 
water may increase distress by overburdening the 
stomach, which does not readily empty itself. 



6 HEAT AND INFANTS 

HEAT AND INFANTS 

The death-rate from diarrheal diseases is twice as 
great in summer as in winter. Short-lived high tem- 
perature may cause some heat deaths of infants, but 
does not much affect the death-rate from gastro- 
intestinal disturbances, unless it should cause an 
unfavorable turn during an acute attack of the trouble. 
On the other hand, continued excessive heat does cause 
an increase in the death-rate from diarrheal diseases 
in infants, although the heat alone is not the only fac- 
tor. Germs that cause intestinal disturbances seem 
to grow better in hot weather, although hot weather, 
if causing an increased temperature in the child, seems 
to lower the tolerance to starchy foods.^ 

Hence the prevention of these disturbances and the 
saving of life will be caused by shady verandas, roof- 
gardens, trees, parks, seashore resorts and cool eve- 
ning country air. 

Previous knowledge has recently been confirmed^ 
that more than one-half of the deaths of children 
under 1 year of age are due to disorders of nutrition, 
and about 75 per cent, of these deaths occur during 
the first three months of life. These statistical facts, 
together with the disturbances caused by the heat of 
summer, emphasize the advisability, if not the neces- 
sity, of a mother nursing her baby during the first 
year of its life, as the mother's milk is ordinarily the 
safest food that the child can receive. 

INFANT AND SCHOOL HYGIENE 

Success in the work which this heading represents 
has been shown by the splendid reduction of deaths in 
young children in cities properly utilizing the knowl- 
edge of medical science and sanitation which we now 
possess. In some cities there has been a diminution 
of more than two-thirds of the deaths from contagious 



1. Zahorsky, J.: Am. Jour. Dis. Child,, November, 1913, p. 318, 

2, Supplement 16, U. S. Pub. Health Rep,, June 19, 1914. 



CHILDREN AND SCHOOL HYGIENE 7 

diseases and of more than one-third of the deaths 
from catarrhal and respiratory diseases of young 
children. 

The foundation of these splendid results, which 
should be studied and inaugurated in all communities, 
are: measures for the purification and proper refrig- 
eration of milk; instruction in the proper preparation 
of milk as a food for infants ; the house visits of 
trained nurses ; the babies' aid, and mothers' aid socie- 
ties; school inspection; school hygiene (good light, 
aided by the proper color tints of walls and ceilings, 
proper desks and chairs, rest and exercise periods) ; 
play-grounds; open-air schools; segregation of defec- 
tive from normal children, etc. 

It is not the purpose in these articles to discuss in 
detail these great problems, but only to suggest that 
those interested, and those who should be interested 
on account of their official positions, should read and 
study the statistics already published. It is desired to 
urge the necessity of careful, skilled school inspection 
and to urge on school boards that proper light saves 
eyes; that proper desks and chairs prevent scoliosis 
and other deformities; that good ventilation prevents 
respiratory troubles; that clean books, pencils, desks 
and chairs prevent eye, nose and throat inflammations, 
to say nothing of the contagious diseases ; that proper 
rest periods save the child's brain from tire; that 
good, well-paid teachers promote education with a 
minimum amount of brain fatigue in the child and 
cause the child to cooperate with, and not combat, the 
instruction offered. Also, means must be inaugurated 
to feed underfed children. 

The necessity of school inspection is readily shown 
by quoting AUport's^ figures, viz. : 

There are in public schools in this country 20 million 
children, and 75 per cent, of these are suffering from some 
defect that can be cured, or at least ameliorated; 500,000 of 

3. Allport: Arch. Pediat, June, 1913. 



8 SCHOOL HYGIENE 

these children have heart lesions; 1,000,000 have spinal cur- 
vature or other defect; 1,000,000 have tuberculosis; 1,000,000 
have defective hearing; 5,000,000, or 25 per cent., have defec- 
tive vision ; 5,000,000, or 25 per cent., are underfed or wrongly 
fed; 6,000,000, about 30 per cent., need operations on the 
tonsils or adenoids, and 10,000,000, or 50 per cent, have 
defective teeth. 

Skilled school inspection probably reduces the 
deaths from contagious disease by 50 per cent., and 
perhaps the total number of contagious-disease cases 
by 75 or 80 per cent. Also, the improved hygiene of 
schools and the improvement in health caused by the 
correction of defects discovered by medical inspec- 
tion must greatly reduce the instances of contagious 
disease. 

The value of regulated and supervised calisthenic 
exercises for schoolchildren is great. These should 
teach correct standing, correct walking, correct breath- 
ing and such muscle exercise as will develop all parts 
of the body symmetrically. Dancing under a skilled 
teacher is valuable exercise, if not too long continued, 
or if it does not add one more preventive of the child's 
enjoying good out-door play and walks. 

The dance craze of this age is deplorable. The harm 
done sexually, neurotically and physically to youth 
and young adults is terrible to contemplate. The harm 
done to old men and women is ridiculously unneces- 
sary. 

Skilled, corrective muscle exercises to remedy 
defects in deformed children are necessary to prevent 
the deformity becoming permanent, and it is a crime 
to neglect such treatment. 

More detailed suggestions for school inspection will 
be presented later. 

AIR 

There has been a good deal of misunderstanding 
as to what constitutes impure air. There is always in 
the ordinary respired air of buildings and houses too 
little carbonic acid gas to do any harm to an individ- 



AIR 9 

ual. Also, a varying content of oxygen, within ordi- 
nary limits, is not an important factor in the effect of 
the air on human beings. It is only heat and extra 
moisture in confined, respired air that is depressing. 
Also, stagnant air is more depressing than air in 
m.otion, even when it is of the same constituency. Of 
course, dust-laden air is always injurious. In artificial 
ventilation in hospitals, schoolrooms and auditoriums 
screening from outside dust and vacuum-cleaning 
from inside dust are essential ; in fact, stagnant dust 
is bad and moving dust is worse. 

Too great heat is often maintained in winter in 
schoolrooms and hospital wards, especially in those 
for children. Also a great variation of day and night 
temperature in hospital wards is not advisable. While 
dry air is not necessarily unhealthful, as noted in 
high altitudes, deserts, plains, etc., still a normally 
regulated moisture should pervade hospital wards and 
operating-rooms, which latter are generally too dry, 
unless steam sterilizers are in use. Schoolrooms not 
overheated will probably be normally moist from out- 
side air. 

One great disadvantage of stagnant, overheated, 
overmoist air seems to be its effect on the skin. The 
skin cannot normally breathe, so to speak; moisture 
remains on its surface, the skin glands cease to prop- 
erly act, and the surface circulation and heat elimina- 
tion are interfered with and the person feels depressed, 
metabolism is impaired, the appetite fails and loss of 
nutrition occurs. Everyone realizes the refreshment 
felt when a window is suddenly opened in a stagnant 
room. Hence the danger to health in a school, fac- 
tory or store where the air is stagnant, dusty, over- 
moist or overheated. 

The value of the open-air treatment of many dis- 
eases has been incontrovertibly demonstrated. Over- 
heated rooms are bad for the sick, and especially bad 
for sick babies. An infant may have his body tem- 



10 BAD HABITS 

perature raised by a continued sojourn in an over- 
heated room or by being long subjected to summer 
heat, at 85 F. or over. 

BAD HABITS OF CHILDHOOD 

It is only necessary here to name some of the habits 
that are subversive of the future good health of the 
child. The physician should be alert to these causes 
of poor health and nervousness in children, and if he 
is, proper preventive or corrective treatment will be 
inaugurated. These bad habits that should be watched 
for are masturbation, thumb- and finger-sucking or 
sucking the pacifier (said by some eminent pediatrists 
to promote the development of adenoids), nail biting, 
imitation movements or habit-spasms and dirt-eating 
or other objectionable eating habits. 

The various local causes of masturbation and of 
bed-wetting must not be forgotten. The eradication 
of such causes sometimes cures the condition like 
magic. 

ACUTE acidosis; autointoxication 

Whether a lessened alkalinity of the blood and 
tissues, or whether an absorption of maldigestive or 
germ toxins is the first factor in this condition, it 
seems to be a fact that the subsequent symptoms are 
largely those of acid intoxication. Any chronic dis- 
turbance may promote acute attacks of this condition, 
such as that due to adenoids ; to chronically inflamed 
tonsils ; to chronic appendicitus ; to maldigestion of fat ; 
to long privation from carbohydrates or to an insuffi- 
cient amount of carbohydrate food; to profuse con- 
tinuous vomiting (starvation acidosis) ; to imperfect 
liver function; to chronic pain as a preventive of 
proper digestion as occurs in ovarian and uterine pain ; 
to severe headache (eye-strain, very frequently), 
besides the acidosis recognized to occur in kidney dis- 
turbances and in diabetes. 

All persons are liable to this acid intoxication, as 
even so-called bilious attacks, sick headaches and 



ACIDOSIS— AUTO-INTOXICATION 11 

acute indigestions cause this condition. Children fre- 
quently suffer from such disturbances. 

The primary symptoms are often quite similar to 
those in the beginning of an acute infection, such as 
diphtheria, tonsillitis, scarlet fever, or even pneu- 
monia; hence, the immediate diagnosis must be 
guarded. A history of repeated attacks will aid in the 
diagnosis. Of all causes, not only in adults, but also 
in children, among the most frequent is eye-strain, 
not recognized for a long time as a cause. The most 
frequently assigned cause is indiscretions in the diet; 
but though such are often causes, especially in young 
children, various articles of food are quite frequently 
unjustly accused. It will often be found that an eye 
pain or a headache preceded the other symptoms, and 
that these attacks may follow definite overuse of the 
eyes, such as looking at moving-pictures, seashore or 
mountain height eye-strain (that is, long distance 
vision), or close observation of moving objects, or the 
addition of long columns of figures, or too much 
kindergarten work, etc. 

The "morning after" nausea and vomiting from 
overindulgence in alcohol is probably largely an acid 
intoxication, although small doses of alcohol in the 
acidosis of diabetes are beneficial when a sufficient 
amount of starch has not been ingested. 

The symptoms of acid poisoning are loss of appe- 
tite; coated tongue, or perhaps the tongue may be 
abnormally red ; often nausea and vomiting ; constipa- 
tion; the face is pale, or perhaps flushed; there is 
headache; generally some fever (not often above 
101 F.) in children; the surface of the body is often 
cold in adults; there may be dizziness in adults and 
excessive nervous irritability and excitement in chil- 
dren. The skin may show urticaria, erythema, or a 
punctate rash, or a dark mottling. Some attacks of 
the above character are really anaphylactic attacks, 
and may occur repeatedly after certain foods, but 
others are due to hyperacidity, as evidenced by the 



12 BATHING 

sweet breath and the urinary findings of acetone, 
diacetic and oxybutyric acid. The excretion of urine 
is almost invariably diminished, except perhaps in 
a real migraine attack, and it may show albumin and 
even casts. The duration of these attacks varies from 
a day to a week, depending on the character of the 
exciting cause. 

The immediate treatment is the administration of 
cathartics, alkalies and large amounts of water; high 
enemas, at first for colon washing and later to intro- 
duce physiologic saline and alkalies (such as sodium 
bicarbonate, sodium citrate and potassium citrate) for 
absorption into the blood. Stomach washing is often 
of benefit. 

As soon as vomiting ceases, oatmeal gruel or other 
thin cereal and milk-sugar or glucose should be given. 
The fruit juices, such as orange and lemon, are of 
value. Rest, a bland diet, and daily free movements 
of the bowels and plenty of water taken soon cause a 
complete return to health. 

The preventive treatment is to seek the etiologic 
factor and eradicate it if possible ; if not possible, then 
to prevent the subjective exciting cause, such as a 
misuse of the eyes, ill-advised food, too much fat in 
the food, alcohol, coffee, tea, tobacco, etc. Bad teeth 
and bad throats must be treated. 

BATHING 

As a hygienic measure, bathing goes back to most 
ancient times. Warm and cold water baths, and even 
medicated baths are mentioned in early Grecian 
periods. In the middle dark ages, after the Roman 
period, bathing as a hygienic and therapeutic necessity 
sems to have been forgotten. Interest in public baths 
and medicinal bathing and the hygienic popularity of 
frequent bathing has only within the last thirty or 
forty years been slowly reviving. 

Frequent bathing is essential to remove dirt, sweat 
and skin excretions. Irritating decomposition and 



BATHING 13 

offensive odors are caused by the neglect of bathing, 
to say nothing of such neglect causing many skin dis- 
eases. Proper bathing increases normal excretions 
from the skin and promotes the health of the skin. 
Hot water bathing relieves the congestion of internal 
organs, improves the general circulation, and cold 
water bathing tones up the vasomotor system. A 
normally bathed skin is a better regulator of the 
internal temperature, a better excretor, and has more 
normal sensations (heat, cold, esthesia). Soap, hot 
water and friction are essential to remove dirt and 
sweat. A simple plunge or shower bath, if taken daily, 
and followed by rough-towel friction, may keep the 
skin clean and healthful, but even then a hot soap bath 
is more or less frequently essential. 

The daily cold plunge does not necessarily place a 
man "next to the Gods," as he so frequently thinks it 
does. Such cold plungers are often very proud of 
their accomplishment and sneer at those who do not 
take this daily treatment, and the plunger is likely to 
"thank God that he is not like other men." Very 
many times daily cold plunges or cold showers are 
harmful, especially to those who are underweight or 
are losing too much weight. A daily or nearly daily 
bath of some kind, however, is essential for almost 
every one in order to promote the best of health and 
to prevent some diseases. 

It is not our purpose to describe, or even to discuss 
the various kinds of baths, or hydrotherapy. Medi- 
cated baths, various sweating baths or so-called baths 
(electric light or body baking), mud baths, etc., have 
all their valuable uses, but are not necessary for the 
promotion of health in the well, that is, are not 
hygienic measures. The cold bath may be from 80 to 
70 F. or below. The tepid bath may be considered 
anything from 80 to 100 F. ; anything much over 
100 F. is a hot bath. 

Whenever possible, every family should have a set 
bath tub. Every city should have public as well as 



14 MEAT INSPECTION 

private bath houses and swimming pools, except where 
the climate is warm the year around and good water 
for bathing (fresh or salt) is near at hand. Every 
child should be taught to swim. 

The family physician should be consulted as to the. 
kind of bathing each individual should take, and many 
serious errors would not occur. It is not advisable to 
bathe directly after a meal. Good fresh air is as 
essential for bathrooms as for any other part of the 
house. One respires more while bathing (hot or cold), 
and hence the air should be pure. Friction is a valu- 
able adjunct to bathing. 

The medical value of salt water bathing has been 
overestimated ; it is a pleasure, and it is more exercise, 
especially in surf bathing and swimming, and thus it 
is valuable for the well and strong. The cold air at 
the seashore after the person leaves the water is tonic, 
but may cause chilling in the weak. 

MEAT INSPECTION 

This is to urge the necessity for the state employ- 
ment if skilled meat inspectors for animal food 
slaughtered for local use. The government inspects 
only for interstate and export commerce. Besides 
tuberculous beef, the danger of the human being 
acquiring tapeworms from cysticercus-infected beef 
and pork, and the danger from trichinae should be 
emphasized. It should be known that sheep may also 
be infected by the cysticercus (from dog infection) 
though this is not transmitted to man. Swine, at least, 
are often infected with lung fluke disease. Esthet- 
ically, however, it is not pleasant. The danger lurk- 
ing in ancient cold-storage fowls and turkeys and stale 
shellfish, and shellfish gathered or fattened in sewer- 
age-polluted water, only emphasizes the need of local 
food inspectors, backed by bacteriologists employed by 
local boards of health. 



IMMUNITY AND PROPER FOOD 15 

IMMUNITY TO DISEASE CAUSED BY PROPER FOOD 

Too much fat in food causes the formation of too 
many soaps and a loss of calcium from the body 
through the stools. This leads to acid intoxication, 
and frequently occurs in infants. While carbohydrates 
tend to prevent acidosis, too much carbohydrate in 
children is said to cause a surplus of water in the 
tissues, and this creates a tendency to acquire disease. 
Whether or not this suggestion is true, certain it is 
that a properly mixed diet gives children and adults 
much better power, apparently, to ward off and fight 
disease. A milk diet, for instance, too long continued 
is bad for both child and adult. Young children should 
receive milk, starch and maltose or lactose, and later 
more protein, and they are less likely to acquire infec- 
tion. It is quite probable that the building up of more 
antibodies by richer protein food may be the reason 
that in adults the infection of tuberculosis is generally 
at first local, while in young children the infection is 
likely to be immediately general. 

A well, healthy infant rarely has thrush, while by 
the sickly infant it is readily acquired. 

MOSQUITO PEST 

This ubiquitous tormentor may be eradicated and 
malarial fever abolished in most communities. It is 
only necessary to remember the following facts, and 
to act accordingly: 

1. Salt water marshes diluted by fresh- water 
streams breed mosquitoes; kerosene oil will prevent 
their development. 

2. These salt-water mosquitoes do net carry dis- 
ease. 

3. Fresh-water mosquitoes may carry disease 
(anopheles, malaria; stegomia, yellow fever). 

4. Fresh-water mosquitoes may develop in any lit- 
tle pool of water, in the street, in a back yard, in a 
tin can, in a pail of stagnant water, in a gutter or 



16 MOSQUITOES 

drain, and even when water stands in a vessel in a 
building. 

5. Such pools of water being abolished, no mos- 
quitoes can develop. 

6. Kerosene, 1 ounce to 15 square feet of water, 
added from time to time to water that will not readily 
flow or tends to be stagnant, but cannot be eradicated, 
will prevent all growth of mosquitoes. 

7. Mosquitoes, unless wind-blown, travel only a few 
hundred yards from their source of breeding. 

8. Most disease-breeding mosquitoes are active only 
at night. 

9. Fine mosquito-netting keeps them out of houses. 

10. If they have entered a house they can only be 
thoroughly eradicated by complete fumigation, 

11. If one must go to malarial districts, the prophyl- 
actic dose of quinin is from 3 to 5 grains a day of the 
sulphate. 

According to Orenstein (The Journal, Jan. 30, 1915, 
p. 458), numerous studies by many observers have 
conclusively shown that many species, including such 
proved disease carriers as A. alhimanus, C. fatigans, 
and A. argyritarsis, travel very considerably more 
than '*a few hundred yards." Also, at least certain 
species, and among these the A. alhimanus, travel by 
preference against a mild breeze, one not exceeding a 
velocity of 4 miles per hour. The supposition of mos- 
quitoes being "blown by wind," he believes, is open to 
serious doubt. It is more than likely that they travel 
during the calm immediately following a blow. In 
experimental work carried on in Panama, anopheles 
were invariably caught in larger numbers in the traps 
set on the lee sides of houses. 

A. alhimanus and argyritarsis breed in salt water 
under certain conditions. He has found these species 
breeding very prolifically in lagoons with a chlorin 
content almost equal to sea water. 



OPHTHALMIA 17 

He suggests the perusal of Le Prince's paper in the 
Transactions of the Fifteenth International Congress 
on Hygiene and Demography, and the articles deal- 
ing with mosquitoes in the reports of the New Jersey 
Agricultural Experiment Station. 

OPHTHALMIA NEONATORUM 

The prevention of this disease, so serious for the 
babe's future, is not attained by discussing the value 
of eugenics, or attempting the regulation of prosti- 
tutes, or demanding the always non-successful report- 
ing of gonorrheal cases. It will be more certainly 
secured by insisting that every physician and every 
midwife (by continued and repeated instruction) shall 
use Crede's method, namely, to instill into each eye 
of every new-born babe 2 drops of a 2 per cent, solu- 
tion of silver nitrate. Every eye inflammation in the 
new-born or occurring shortly after birth should be 
considered ophthalmia until the microscope shows that 
it is an innocent inflammation. If gonococci are 
found, the little patient should be placed in the care 
of a skilled oculist. 

TONSILS 

The danger from chronically diseased tonsils is not 
sufficiently recognized by the majority of physicians, 
although specialists and bacteriologists have long 
urged that they are a menace to health and should be 
extirpated. Some laryngologists, and they have a 
goodly number of internists as followers, would extir- 
pate (enucleate) all tonsils that have the least signs 
of chronic inflammation, especially if they are even 
slightly enlarged. 

Before advising radical operation, that is, enuclea- 
tion, it should be remembered that these glands prob- 
ably have a function as outposts of our fortifications 
against disease germs, and when they are extirpated 
or are hopelessly diseased the deeper neck and bron- 
chial glands become more readily affected by patho- 



18 TONSILS 

genie germs. It should be remembered that complete 
enucleation is a major and serious operation. With 
the above caution, the therapeutic necessity of eradi- 
cating all diseased tissue in a tonsil by slicing, curet- 
ting, cauterizing, or, if need be, complete enucleation, 
is strongly urged. Also, as a measure of disease pre- 
vention, to eradicate tonsils containing infected pock- 
ets is more necessary than to pull or fill a decayed 
tooth. 

It should be recognized that a tonsil may be badly 
diseased and yet not be prominent. Also, disease may 
proceed from a tonsil and yet there may be no imme- 
diate preceding tonsillar inflammation. 

It has been shown that pathogenic germs, as pneu- 
mococci and various streptococci, especially hemolytic 
streptococci, may be harbored in diseased tonsils. 
These germs have been found so many times in acute 
and chronic arthritis and acute and chronic endo- 
carditis, and in other infections, as to show a direct 
causation. 

The surface bacteria may not give the cultures that 
the deeper-seated pockets or abscesses in the tonsils 
produce. Hence, in rheumatic cases, before the ton- 
sils are considered innocent, whether a tonsillitis pre- 
cedes the rheumatic attack or not, a careful examina- 
tion of the tonsils should be made. 

Infected tonsils may be the cause of influenza, 
chorea, nephritis, endocarditis, and various pyemic 
and septic processes, as well as of rheumatism. In 
fact, all and more than has been said of infected 
gums and teeth may be said of the danger of chronic 
suppuration in tonsils. The relation of tuberculosis 
to the tonsils has long been known. It is quite sup- 
posable that anemia, meningitis and neuritis could 
emanate from infected tonsils as well as from infected 
gums. While all diplococci found on tonsils are not 
pneumococci, the latter are found often enough to 
show that they could be a cause of pneumonia through 
the infection of others, if not in the carrier. Diph- 



PREVENTION OF CONTAGION 19 

theria, follicular tonsillitis, and, doubtless, scarlet 
fever, are caused by infection from carriers who have 
the causative germs of these diseases on or in their 
tonsils. 

To summarize: 

1. The total extirpation of non-suppurative tonsils 
is not necessary. 

2. The extirpation of all diseased parts, or total 
extirpation, if it is necessary to eradicate the diseased 
portions, is proper treatment and advisable as soon 
as discovered. 

3. Operative interference is therapeutically urgent 
in all cases of recurrent tonsillitis, in rheumatic cases, 
acute or chronic (arthritis deformans), in nephritis, 
etc., if the tonsils are found diseased. 

PREVENTION OF CONTAGION 

Before disease can be prevented its source and its 
method of transmission must be known. This is too 
large a subject to treat here, but a brief summary of 
our present knowledge and of the objects aimed at 
will be of interest. 

To the greater part of the United States, cholera, 
yellow fever, bubonic plague, some so-called malarial 
fevers, some dysenteries, and some other diseases, are 
practically foreign. The cholera bacillus reaches us 
in ships, and quarantine and governmental control 
takes this dread disease out of the hands of the indi- 
vidual practitioner. Suffice it to say that stool and 
urine disinfection, screening against flies, and boiling 
and using superheated plates and eating utensils, a 
supply of clean drinking-water and eating with clean 
hands are the key notes to the prevention of the 
infection of others. The prevention of dysentery and 
typhoid fever, both due to known germs, is not dis- 
similar. Yellow fever infects us by means of con- 
taminated mosquitoes; hence, every case is a menace 
unless absolutely screened from these insects. The 



20 CONTAGION 

same is true of malarial fever. Bubonic plague is dis- 
persed by the bite of fleas from infected rats. Gov- 
ernmental control of this disease when it entered San 
Francisco rapidly eradicated it by destroying the 
infected rats. 

Typhus fever is spread by infected body-lice and at 
times by head-lice. Brill's disease is a form of typhus. 
The necessity of scrubbing and absolutely cleaning all 
places of close confinement and all individuals who 
are confined or about to be confined therein is self- 
evident. 

It has long been known that certain diseases are 
contagious and transmitted from person to person, 
but it is only within recent years that the actual germs 
of disease have been discovered, and still more 
recently that in some instances the exact method of 
infection has been discovered. Formerly the con- 
tagious element was supposed to be carried in cloth- 
ing, baggage, money, rags, etc., and to cause the dis- 
ease when the innocent individual came in contact 
with such infected materials. In the case of scarlet 
fever it has until recently been believed that the 
desquamating skin, the epidermal scales, carried the 
infection. It has now been pretty thoroughly demon- 
strated that such is not the fact, that the infection 
of scarlet fever comes from discharges and secretions 
of the mucous membranes of the nose and throat and 
from ears that are suppurating from this disease. 

It has been long known that the eruption of measles 
does not carry the contagion, but that the contagion 
is transmitted by means of the nose and throat secre- 
tions. 

Theoretically, dirty money, especially paper cur- 
rency, handled by all kinds of people and by people 
suffering from or in close contact with contagious dis- 
eases, should transmit disease; but it has not been 
found to do so. Bank men and treasury department 
men who handle large amounts of gold and dirty 
money do not contract disease. This does not excuse 



ISOLATION— CARRIERS 21 

the disgusting practice of putting coins in the mouth, 
or of wetting the fingers with the tongue in count- 
ing bills. Certainly, every individual who handles 
money should frequently wash his hands, especially 
before eating, and before handling food for the use of 
others. 

Many kinds of bacteria have been found on stair- 
ways, balustrades, car straps and on money, but gen- 
erally such bacteria have been found to be non- 
pathogenic. Such negative findings, however, and the 
lack of demonstration that disease is frequently trans- 
mitted by such methods, do not controvert the pos- 
sibility that occasionally infection may be transmitted 
from one infected person directly to another by 
immediate contamination of some article. This pos- 
sibility only emphasizes the necessity for the more 
or less strict isolation of infections, and the strict 
observance by an infected individual of the rules and 
regulations for the prevention of infection of others 
which are prescribed for the particular disease that 
he has. 

The greatest factor in the spread of infection in 
any community or in any associated group is the germ 
carrier; and the more innocent the individual is of 
the fact that he is a carrier of pathogenic organisms, 
the greater the danger to the people who surround 
him. Therefore, in every epidemic, carriers should be 
sought for and when discovered should be isolated and 
treated. Also, a patient recovering from a contagious 
disease should be proved not to be a carrier before 
he is dismissed from quarantine or isolation. Another 
great source of the infection of others is by mild cases 
of infection in which the individual is not sufficiently 
ill to remain in the house. Also, some of the chil- 
dren's infections are transmitted in such early stages 
that the child is not supposed to be ill, or at least is 
not supposed to have a contagious disease. This is 
notably true of measles. 



22 CONTAGION— DISINFECTION 

Since it has been determined that direct contagion 
is almost a universal method of transmission of many 
of the contagious diseases, and that clothing and bag- 
gage are rarely, if ever, agents of such transmission, 
it is evident that some of the measures which have 
hitherto been employed to diminish the danger of con- 
tagion have been of little or no value. Fumigation of 
rooms, apartments, houses and buildings by various 
chemicals, is, in most cases, a waste of time, energy 
and money. It having been determined that most of 
the contagious diseases are transmitted by secretions 
from the nose and throat or mucous membranes, or 
are eliminated with the excretions, cleansing, and per- 
haps in some instances antiseptic nose and mouth 
sprays and gargles, and the immediate destruction, 
either by chemicals or by heat, of all germs that leave 
the body either by the urine, feces or mucous dis- 
charges, and the cleansing with antiseptics of all 
objects in contact with or in the immediate region of 
the infected patient, are all sufficient to prevent con- 
tagion. All discharges from the noses and throats 
of patients who are ill from almost any cause should 
be received into cheesecloth or paper napkins, and 
these should be immediately placed in a paper bag 
which should be burned. 

Many antiseptic or disinfectant solutions used for 
the stools and urine are not satisfactory. Bed-pans 
or other vessels used for receiving the excretions 
should be cleansed with boiling water or steam. The 
urine should be received into a vessel which contains 
a strong antiseptic, as a chlorinated-lime solution 5 
per cent., or mercuric chlorid solution 1 : 500, The 
urine should then stand in this covered vessel for an 
hour or more before it is thrown down the closet. The 
same solution may be used to receive the fecal mat- 
ters, at least in all diseases in which the feces carry 
infection ; but it is here necessary for the fecal deposits 
to be broken up, that the germicidal fluid may act on 
all parts. Chlorinated lime may well be added to the 



SEASONS AND HEALTH 23 

mixture, an equal volume of a 25 per cent, mixture, 
and the whole tightly closed and allowed to stand for 
two hours or more before it is permitted to pass into 
the sewer. While boiling these excretions is the 
surest and most complete way of killing all germs and 
spores, in private families this would be a disagreeable 
and inconvenient method. In hospitals efficient steam 
or boiling measures for sterilizing all excreta should 
be installed. All possibly contaminated articles of 
clothing, bedding, rugs, carpets, etc., should be sub- 
jected to heat or steam, if such cannot be actually 
boiled. All other objects in the room may be well 
cleansed by washing or scrubbing with formaldehyd 
or mercuric chlorid solutions. Fumigation of the 
rooms with sulphur and formaldehyd, if not useless, 
is not sufficient. 

EFFECT OF SEASONS ON HEALTH 

A positive indication of the effect of this factor 
on public health can be obtained by the death-rate 
in the registration areas for the different months of 
the year. Many studies of these statistics have been 
made, and it seems to be a- fact that the greatest 
mortality usually occurs in the month of March, 
although sometimes January surpasses March in mor- 
tality, and February follows closely. In July and 
August, also, the death-rate is somewhat higher than 
in the immediately preceding and succeeding months, 
while the minimum death-rate generally occurs in 
June, and November is usually the month of next 
lowest mortality. These statistical facts are not sur- 
prising, as it has long been recognized that the highest 
mortality occurs in the months characterized by 
extremes of temperature, the hot weather of July and 
August causing a large mortality among children, 
while the cold weather of January and February 
causes a high death-rate from diseases of the respira- 
tory system. Many old people and many feeble per- 
sons who may have combated and survived the sever- 



24 WEATHER AND HEALTH 

ity of January and February are quite likely to 
succumb in March. Also the relaxation of a little 
warmer weather causing more or less carelessness 
among the well makes March the month of the great- 
est number of deaths. 

Besides the morbidity and mortality associated with 
these extremes of temperature of summer and winter, 
various other factors must be taken into account. 
Such are local climatic conditions, as peculiarly 
unhealthy weather may prevail in a region, at any 
season, and cause the death-rate to be abnormal for 
that season. Persistent and recurrent rain or snow, 
dark days, or excessive humidity may so depress indi- 
viduals that they become more susceptible to disease; 
and the ill do not so readily recover as when the 
weather is pleasant. Epidemics of various kinds may, 
of course, also increase the death-rate at any season. 

While it is the sick, the weak, the old, and the very 
young who are especially likely to suffer from exces- 
sive heat or severe cold, even the strong and the robust 
are affected by climatic severities, and a larger pro- 
portion of the well become ill, especially with the 
intense heat of summer. 

To prevent illness in hot summer weather, persons 
should not unnecessarily expose themselves to the rays 
of the sun, and should especially avoid severe exercise 
in the heat when it is not necessary. This is a special 
warning for those who take hard exercise, in vaca- 
tion recreations or amusements, in the sun in the mid- 
dle of the day. Such persons, also, are often not 
used to such exposures, their work being mostly 
indoors. 

The air in cities is likely to be more dust-laden and 
more impure in hot weather than in cold weather, as 
however well the streets are watered, the dust on 
houses and buildings and in crevices more readily 
dries sufficiently to be wafted by the least breeze. 
Also decomposition of all animal matters occurs more 
rapidly and more readily contaminates the air. Con- 



SUMMER HEAT 25 

sequently, because of the heat and this air impurity, 
all those who are able leave the city and seek the 
seashore or the country. Such changes of location 
are not always a panacea, as, if such individuals are 
compelled to lose all their home comforts, if they 
must sleep in small, ill-ventilated rooms and in 
crowded quarters, if they are pestered with mos- 
quitoes and their food is covered with flies, as obtains 
in so many summer boarding houses, and if the sea- 
food presented is not immediately from the water or 
properly refrigerated, the harm done is greater than 
the good. Many things should be considered by the 
individual or the family and by the family's physi- 
cian before the summer abode is changed. This is 
not to minimize the great advantage of vacations and 
of fresh, clean, seashore and country air, provided 
other dangers are not incurred. Also, the danger of 
overdoing seashore bathing must not be forgotten. 

For the many individuals or families who cannot 
leave their homes, or to whom it seems unwise to do 
so, the summer may be rendered more comfortable 
by properly screening the windows and doors from 
flies and mosquitoes and still allowing free circula- 
tion of air, screening of verandas or balconies, if 
such is advisable, resting as much as possible during 
the interim from labors, and not taking severe and 
uncomfortable trips or amusements to add to the 
exhaustion caused by the work that must be done. 
Many persons come back from excursions or trips, 
after buffeting with the crowds, more exhausted than 
when they left. The trolley trip should be selected 
that gives the greatest amount of fresh air with the 
least amount of crowding and exertion. Cool bathing 
should be advised and urged as a most splendid 
method of lowering the temperature, cleansing the 
skin from perspiration and causing it to become more 
active and thus lowering the internal temperature. 
Of course excess of such bathing should be avoided. 



26 WINTER COLD 

Before leaving this subject of summer heat, let it 
be urged once more that over-eating, late hours, and 
strenuosity in vacation and summer amusements 
should be abolished, and that the prime thing is rest- 
fulness in the coolest, cleanest air that can be obtained. 

Men are not careful enough to wear thin clothing 
and protective, air-cooled hats. In this era nothing 
need be said of the air-cooled clothing of the women 
for summer. Certainly from a physiologic and sani- 
tary, if not a moral point of view, their clothing seems 
unassailable. 

As to the opposite climatic extreme, namely, the 
severe cold of winter, it is equally important that the 
strong as well as the weak should not subject them- 
selves to needless exposure. The strong are likely 
to boast that they do not need overcoats or other means 
of protecting themselves from the cold. Many such 
individuals fall by the wayside, needlessly. The under- 
clothing should be that found best for the individual ; 
whether linen mesh, silk (if one can afford it) or thin 
woolen, is a matter for individualization, modified by 
the region in which one lives, and the work which one 
does. Whether an individual wears overcoats or 
sweaters is a personal decision, but the wearing of 
sweaters all day, at work or in buildings, is a serious 
mistake, which is made frequently by young men. The 
feet should be warm, the kind of shoe depending on 
the weather. High shoes should be worn in cold 
weather and rubbers when it is wet, unless the shoes 
are water-proof. If a child wears rubber boots for 
storm and play, in wet and snowy weather, he should 
not be allowed to sit with them on in school. Rubber 
heels are always good ; rubber soles are a serious mis- 
take, especially in summer, and for one to be insulated 
with these heavy rubber-bottom shoes for hours, or 
all day, is an abomination. Such rubber insulation 
causes the feet to perspire, and causes a lack of tone 
of the feet. 



CLOTHING 27 

The costume and clothing of men in winter does 
not require a great deal of discussion. The clothing 
of women and girls, projected from the summer into 
the winter, is a proposition that it is practically hope- 
less and needless to discuss. They wear furs draped 
around them almost anywhere ; the warmth of the rest 
of their costume is indeterminable. We venture to 
state that the physician of to-day rarely feels more 
helpless than when one of these girls comes to his 
office with a severe cold and cough. He knows that 
it is more care and common sense that cures a cold 
than drugs, and without the two former elements in 
the cure he is forced to rely on drugs in which he 
has but little faith. Any common-sense advice that 
he will give such a girl will either place him in dis- 
favor, or will be received and not acted on. It might 
be parenthetically stated that what is said above also 
generally applies to the girl's mother. 

The clothing of young children in cold weather is 
more often incorrect than correct. Many are over- 
clothed; many are under-clothed. The family physi- 
cian should carefully advise in this important matter. 

Those who habitually live or work in warm rooms 
should be careful to wear clothing of moderate weight 
so as not to be overheated while in the house, but they 
must put on overcoats or cloaks on going out. In the 
northern and eastern parts of the United States people 
are very likely to have their houses overheated in 
winter. A temperature ranging from 68 to 72 F. with 
an adequate amount of fresh air is the temperature 
that is the most healthful. Old people and very young 
children require and must have greater heat than this 
in winter. The best heating system for houses and 
buildings need not here be discussed. 

Individuals who can afford it, and who are weak 
and feel the cold severely, or who suffer more or less 
from bronchitis, colds, or other disturbances due to 
cold weather, should go to a warmer region during the 
winter. If they go to the southern United States, 



28 DUST 

however, they must go far enough south to get the 
warmth, and not into the middle south where it is not 
very warm, and where the houses are not as well 
heated as their own homes. They should go at least 
below South Carolina in the East, and in the West, to 
Southern California, Arizona, or New Mexico. Many 
people who can afford this climatic luxury return to 
their homes too early in the spring, and are more 
likely to acquire severe colds, and even pneumonia, 
than though they had remained at home all winter. 
Also, it must not be considered that these regions are 
exempt from the possibility of severe chilling and 
from pneumonia. Many an individual has gone to a 
warmer climate and acquired pneumonia, and died 
of it. 

DUST 

We have already briefly referred to what is now 
understood as pure air, and the effect of stagnant and 
overmoist air on the individual. The injury caused 
by dust or impure air, however, has not been suffi- 
ciently emphasized. 

The excellent discussion of this subject two years 
ago by Prof. Charles Baskerville of the College of 
the City of New York* has been used as a basis for 
this article. 

For practical purposes the impurities of the air 
may be divided into two classes, dust, and fumes or 
gases. In the cities the dust contains pulverized 
excreta of human beings and animals, the material 
which is constantly being worn from the buildings 
and pavements, the waste from houses, stores and 
factories, micro-organisms, leaves, remains of fruit, 
and other parts of plants and trees. It is interesting 
to know that the air of subways contains many minute 
angular particles of iron. 

In the country the dust consists to a larger extent 
of particles worn from the road. The substances of 

4. Baskerville, Charles: New York Med. Jour., Nov. 23, 1912, 
p. 1061 and Nov. 30, 1912, p. 1119. 



DUST PREVENTION 29 

which the road is composed are more or less pulver- 
ized by the traffic. This dust is especially increased 
by heavy carts and automobiles. The country roads 
are disintegrated in part by the frosts of winter, in 
part by the wind, by the action of the falling rain, 
and by the transporting power of water. Oiled roads, 
as soon as they dry, give rise to particles of crude, 
irritant tar-oil which are wafted with the dust. 

These components of the dust are all more or less 
irritating, not only to the mucous membrane of the 
respiratory tract, but also to the eyes. When the 
amount of dust is small the irritation may be slight, 
but when the amount of dust is large and when there 
is a considerable amount of tar-oil present, the irrita- 
tion may be very troublesome. 

The prevention of this dust is accomplished by care 
in the building and in the maintenance of the roads. 
The best structure for a roadbed and top dressing 
must be decided by the region, by the variations in 
climate, by the geography of the locality, and by the 
character of the traffic. There is doubtless no one best 
roadbed. 

There is no question of the necessity for a city to 
water its streets. There, also, seems to be no ques- 
tion of the advantage of oiling turnpikes and country 
roads, if they are built of material that allows of 
oiling. Whether or not a city should oil its streets 
is a subject for discussion. 

Baskerville suggests as a suitable disinfectant and 
agent for the diminution of dust a very dilute chlor- 
inated lime solution. The chemical is cheap, and any 
outlay entailed would be more than covered by the 
decrease in dust-borne diseases. He also calls atten- 
tion to Dr. Nesbit's work in ridding Wilmington, 
N. C, of flies by sprinkling the streets five times with 
an attenuated mixture of water with light pine-oil. 
An incidental effect of the suppression of the flies 
was the stamping out of a typhoid fever epidemic. 



30 IMPURE AIR 

The other part of the impure air problem has to do 
with noxious fumes and gases, and is especially 
important in cities. There may be mentioned first 
the danger from illuminating gas. The chief poison- 
ous constituents of this are "ammonia, hydrocyanic 
acid, hydrogen sulphid, carbon disulphid, other gas- 
eous sulphur compounds, and carbon monoxid." The 
danger from the inhalation of concentrated illumin- 
ating gas, such as is often taken with suicidal intent, 
are too well known to require repetition, but the 
hygienic importance of good ventilation and the con- 
stant renewal of outside fresh air to a room where 
illuminating gas is constantly, or for a long time, 
burning is not sufficiently understood. Also, the 
depressing influence and the actual blood disturbances, 
even anemia, caused by the constant inhalation of the 
gas from an illuminating-gas leak in a house or build- 
ing is not sufficiently noted, and is not investigated 
by boards of health as it should be. Leaks of illumi- 
nating gas, which occur so constantly and frequently 
in tenement houses, stores and factories, have not 
been sufficiently considered as a menace to health. 

The atmosphere outdoors in manufacturing towns 
is contaminated extensively with the smoke produced 
by the combustion of large quantities of coal. The 
combustion gases from this source are of a highly 
poisonous nature. They may be diminished to a con- 
siderable extent by proper management of the fires 
by skilled firemen. An important constituent of this 
smoke is the soot, which is due to incomplete com- 
bustion, and which may be "formed partly by the 
mechanical removal of dust by the chimney draft, 
and partly by the decomposition of the fuel, such as 
takes place in the process of destructive distillation. 
It consists mainly of carbon, tar and ash or mineral 
matter together with sniall amounts of sulphur and 
nitrogen compounds, and often possesses an acid char- 
acter." The sticky properties of soot are due to the 
tar which it contains. 



CLASSES OF DUST 31 

Sulphur dioxid is one of the most important impuri- 
ties of city air, especially in manufacturing towns, and 
this is derived to a large extent from the combustion 
of coal and of coal gas. Its presence in the air has 
a serious efifect on susceptible persons, and particu- 
larly damages the respiratory organs. It tends to 
cause anemia and bronchitis. Various efforts are made 
to discourage the dissemination of smoke in communi- 
ties. It has been suggested that more might be accom- 
plished if the matter were placed by municipalities 
and boards of health "in the hands of men qualified 
to assist manufacturers to suppress the nuisance with- 
out causing them difficulty." Methods have been 
invented whereby much of this waste combustible 
material may be collected with profit to the manu- 
facturer and with health and happiness to the sur- 
rounding community. The smoke nuisance should be 
most seriously considered by all cities. 

The dust which is present in the air of many shops 
and factories, and which is produced incidentally to 
the various processes employed in the mechanical arts, 
is a factor of considerable importance in connection 
with the health of the workmen. 

These dusts may be divided into three classes: (1) 
insoluble inorganic dusts; (2) soluble inorganic dusts, 
and (3) organic dusts. 

The first class, the insoluble inorganic dusts, 
includes metals such as antimony, arsenic, type metal, 
brass, bronze, copper, aluminum, iron, steel, lead, 
manganese, silver, tin and zinc, in a state of fine 
division; also various ore dusts such as that from 
iron ore, silica, sand, emery, flint, glass powder, car- 
bon, graphite, diamond, coal, soot, brick dust, marble, 
granite, cement, terra cotta, lime, gypsum and plaster. 

The second class, the soluble inorganic dusts, 
includes substances which may be swallowed and 
absorbed, such as metallic particles like lead, brass, 
zinc, arsenic, mercury and silver, and soluble inor- 
ganic salts. 



32 EFFECTS OF DUST 

The third class, or organic dusts, includes "saw- 
dust, fur, skins, feathers, broom and straw, grains 
and flours, jute, flax, hemp, cotton, wool, carpet dust, 
street sweepings, tobacco and tobacco-box dust, hides 
and leather, felts, rags, paper, horsehair, etc." 

These various dusts affect chiefly the respiratory- 
organs, but to a less extent the eyes and the skin. In 
the lungs they produce a condition of fibrosis of the 
lung to which Zenker gave the name "pneumono- 
koniosis." Various forms of this disease have been 
described, depending on the nature of the irritant 
producing the fibrosis. Among them may be men- 
tioned anthracosis, or coal-miners' disease, caused by 
the inhalation of the dust from anthracite coal; 
siderosis, caused by the inhalation of the dust from 
metals, especially from iron, and chalicosis, caused by 
the inhalation of mineral dusts, resulting in the 
so-called stone-cutters' phthisis and grinders' phthisis. 
The inhalation of iron dust diminishes the respiratory 
efficiency of the lungs by causing a lessening of their 
elastic property. It may also reduce the resistance 
of the lungs to invasion by harmful bacteria. That 
form of disease distinguished as siderosis exists with 
special frequency among metal polishers, knife grind- 
ers and others engaged in metal work. 

Among the diseases caused by the organic dusts may 
be mentioned flax dressers' disease, a kind of pneu- 
monia due to the inhalation of particles of flax and 
alkaloidal poisoning from African boxwood, seen in 
workmen engaged in shuttle making. 

The prevention of these various forms of disease 
incidental to various forms of industry without unduly 
interfering with the profits of the business is often 
an exceedingly difficult problem. Among the sug- 
gestions which have been made, and which are 
employed with more or less advantage may be men- 
tioned : 

1. The removing of the dust from the room in 
which it is produced by forcible suction applied at the 



COLON BACILLUS 33 

seat of its production. This is especially applicable 
in the trades of grinding and polishing. 

2. When irritating dust affects the eyes, glasses 
for their protection should be worn by the workmen. 

3. Those engaged in sorting rags in paper factories, 
workmen on threshing machines, millers, mixers in 
glass factories, stone cutters, sculptors and all others 
in factories where there is irritating dust should wear 
respirators over the mouth and nose to prevent the 
dust from entering the respiratory organs. 

4. Those employed in the manufacturing of oxidiz- 
ing agents or lead workers should change their clothes 
before leaving the factory. 

5. The dust on the floors of printing, type-casting, 
metal-working and similar establishments should be 
laid by means of certain preparations adapted for this 
purpose. Probably the best are mineral oils which 
accomplish this result very satisfactorily. 

6. General ventilation of the shop should be 
employed as far as practicable to dilute the unavoid- 
able dust and remove it as far as possible. 

7. The value of vacuum cleaning for factories 
should be emphasized as much as it is for office build- 
ings, stores and private houses. 

THE COLON BACILLUS 

We harbor, more or less normally, some germs that 
may become pathogenic, notably the colon bacillus. 
The part this germ plays in causing acute inflamma- 
tion or chronic disintegration of organs is variously 
stated, but it seems ever ready to attack us when our 
armies of protection are reduced in number or other- 
wise engaged. It has been suggested that this germ 
or its toxins may be a cause of neurasthenia, arterio- 
sclerosis and chronic nephritis, if not of liver distur- 
bances and cerebral disturbances. It has been shown 
to cause appendicitis, cholecystitis, and perhaps pyeli- 
tis. It is thought by some to be a cause of the ever- 



34 INTESTINAL PUTREFACTION 

frequent duodenal and gastric ulcers. It may play 
an important part in the pernicious anemias, which 
are now thought to be generally due to an infection. 
Not infrequently, in acute disease, complications occur 
which are attributable to the colon bacillus or its tox- 
ins. Often some chronic catarrh has been shown to 
be complicated, if not caused, by infection with the 
colon bacillus. 

Whether there are other normal bacilli in the human 
body that under certain conditions may become patho- 
genic has not been discovered, but certain it is that 
in the prevention of disease we must take into con- 
sideration not only the infective but the putrefactive 
power of the colon bacillus. The prevention of 
putrefaction in the intestines will promote the imme- 
diate health of the individual and may prevent or post- 
pone future organic disease. 

Not to discuss the treatment of localized infection 
from colon bacilli, it may be stated that the treatment 
of intestinal putrefaction is, unfortunately, unsatis- 
factory. The prevention of constipation, withholding 
meat, including fish and poultry, from the diet, the 
administration of lactic acid bacilli as such or as 
soured milk, or the administration of yeast, and the 
cure of any gastro-intestinal inflammation that may 
be present by proper dietary, medicinal or surgical 
treatment, may prove very successful for some years 
in staying or preventing intestinal putrefaction. 
Although later to be discussed, it may be here urged 
that healthy teeth and gums are essential factors in 
the cure of intestinal fermentation. 

C. E. A. Wilson (Jour. Med. Research, Vol. X, 
No. 3, p. 463) states that the colon bacillus is found 
on the hands of 5 to 10 per cent, of people examined, 
showing how careless this proportion of individuals 
are. The fact that colon bacilli have been found on 
hands carries with it the probability that typhoid 
bacilli may be carried and may contaminate food or 
other articles in this way. 



MINE SANITATION 35 



MINE SANITATION 



While this subject is not of much general impor- 
tance, it is of great importance to some of us, and 
should interest all. New methods of saving life and 
of avoiding accidents, and the condemnation of crim- 
inal carelessness should ever be subjects worthy of 
careful review, if not of individual study. 

Mine problems, so well understood by some physi- 
cians, but so little by the majority, are splendidly out- 
lined in an article by Dr. N. P. Brooks^ which it 
would be well for all interested to read carefully. 
The main points for consideration are proper and 
scientific ventilation, proper lighting methods, methods 
to diminish dust, proper drainage, proper disposal of 
excreta of men and animals, and a greater care of the 
personal hygiene of the miners. 

Briefly, the gases in coal mines are as follows: 

CH4, methane or marsh gas, is "colorless, odorless, 
tasteless, lighter than air, in a pure state burns with 
a blue flame, and is very explosive when mixed with 
certain proportions of air." When breathed in a 
pure state it affects the individual not unlike laugh- 
ing gas, and does not cause harm when inhaled as long 
as the supply of oxygen is sufficient. 

CO, white-damp or carbon monoxid, "is a colorless, 
odorless, tasteless gas, lighter than air, combustible, 
and explosive when mixed with a certain proportion 
of air." This gas is very poisonous, and if 1 per cent, 
of it is breathed for any length of time it produces 
dyspnea, headache, loss of sight, soon paralysis, begin- 
ning with the lower extremities, and finally uncon- 
sciousness. When unconsciousness is caused by car- 
bon monoxid the patient may not be resuscitated at 
all, or if he is, his mentality may be seriously injured. 
A positive indication that this gas is accumulating in 
dangerous amount is shown by the death of white 
mice or other small animals, that should be kept in the 

5. Brooks, N. P.: Month. Cyc. and Med. Bull., April, 1913, p. 203. 



Z6 MINE GAS 

mines where their condition can be readily observed 
by the miners. 

CO2, carbonic acid gas, carbon dioxid, "is a color- 
less, odorless, tasteless gas, heavier than air, and a 
non-supporter of combustion." The presence of this 
gas in abnormal amount is readily detected by the 
dimness of the oil lamps. The first symptoms of a 
poisonous amount of this gas are increased heart 
action, lassitude, and headache. If the amount of 
the gas is very considerable the individual may fall 
unconscious without even a cry. Men subjected to 
this poisoning may remain unconscious for some 
hours, provided they get a sufficient amount of oxy- 
gen, and still be resuscitated. "Suffocation ensues 
when there is 1 volume of this gas to 12 volumes 
of air." 

HgS, hydrogen sulphid, stink-damp, does not fre- 
quently occur in mines, but is very poisonous. Its 
obnoxious odor causes it to be quickly detected. 

Lighting, ventilation and methods of diminishing 
dust are too technical to be discussed here. Careless- 
ness in the drainage of mines, from the effect that 
bad drainage can have on the miners, should not be 
tolerated. Miners who must work all day with wet 
feet are certainly rendered liable to colds, joint affec- 
tions and neuritis, if not to more serious illnesses. 
If they are barefooted, in certain regions, they are 
liable to acquire the hookworm disease. If they work 
in rubber boots, the sweating and general lack of 
elasticity caused by standing all day in rubber is a 
distinct disadvantage to the individual. 

The care of the excreta in mines should certainly 
be under the control of the boards of health in the 
regions in which the mines are located, and sanitary 
measures, now well understood, should be established 
in every mine. The clothing and cleanliness of the 
miners and their drinking habits should all be subject 
to careful supervision, the two former for their indi- 
vidual welfare, and the latter not only for their own 



EUGENICS 2n 

welfare but for that of others, as carelessness is an 
important factor in mine disasters. 

As first aid to the injured in accidents and mine 
disasters must frequently be rendered by fellow 
miners or their foremen, instruction should be given 
to all in artificial respiration, in methods of stopping 
hemorrhage, in the first antisepsis and dressing of 
injuries, and in the action of the different poisonous 
gases. Foremen should pass an examination on such 
subjects. 

EUGENICS 

This very large social, economic, medical, religious 
and legal subject should receive a passing thought 
in this series on preventive medicine. 

Briefly, heredity and environment are the two fac- 
tors that are most prominent in the production 
of physical and mental health. Environment may 
improve or mar heredity, but cannot change it. 
Heredity is therefore the most important factor in 
raising and developing an ideal race. Scientific 
selection in breeding animals and plants has proved 
its value beyond all possible refutation. The impor- 
tance of good environment for the perpetuation of 
physical and mental health is so well understood that 
it requires no discussion. But environment will not 
eliminate a hereditary tendency to disease or to mental 
or physical insufficiency. Neither will environment 
develop perfect mental and physical health when 
there is an inherited deficiency, although environment 
can markedly improve deficiency caused by injury or 
acquired by disease. 

The long gestation, still longer nursing, and yet 
longer helpless period of the human embryo and 
human infant demand the long nourishing care of the 
mother by the father and by the community. This 
means that for at least two years the father must 
provide food, protection and comfort, if not luxury, 
for the mother and child as well as for himself. If 
he fails in this duty, some other person, some charity, 



38 WHO SHALL MARRY 

or the community must assume the duty. This being 
the fact, worthless, incapable and mentally or physi- 
cally diseased fathers are a tax on the community. 

All kinds of beautiful and necessary charities are 
succeeding in their aim to raise to adult life defec- 
tive children, as well as to save the well and strong. 
A large number of these mentally, physically, and 
often through heredity, morally defective persons 
assert the right to marry, and do so, and another crop 
of defective children is the result. Our orphan 
asylums, hospitals, sanatoriums, homes, insane asy- 
lums, jails and prisons are being overfilled in con- 
sequence of the foregoing conditions. What are we 
going to do about it? 

The environment of prospective fathers and 
mothers and their future children is being constantly 
improved by the public health advances now being 
made in all communities, but as has been stated, this 
will not prevent the ravages of inherited disease 
(syphilis, epilepsy, insanity, imbecility, physical weak- 
ness) or of the inherited tendency to disease (tuber- 
culosis, cancer, gout, diabetes, alcoholism, etc.), any 
more than environment can produce twins, beauty, 
geniuses or permanent health. In fact, improved 
environment is doing more for the defectives in all 
lines than for those of good heredity, who would 
survive a less improved environment. 

The question for discussion, then, in this one on 
eugenics is, who shall marry, and who shall have 
children? It seems doubtful whether the law or the 
state can, in the present status of the human age and of 
civilization, enforce scientific selection or compel com- 
plete physical and mental examination of a man and 
woman before they may be allowed to marry. Public 
health and welfare education, medical teaching and 
instruction, and the higher education emanating from 
the church may, in a few decades, make this problem 
one that is readily decided by the families of the con- 
tracting parties, or even by the young man and young 



MARRIAGE OF DEFECTIVES 39 

woman most deeply interested. On the other hand, 
it is possible that the age is ripe for an insistence that 
known defectives and known diseased individuals be 
allowed to marry only when the other member of the 
contracting parties is made cognizant of the fact, and 
also that means be taken to prevent offspring from 
such alliances. Such defectives often breed readily 
and lavishly, and their progeny are often no comfort 
to themselves, and are more than likely to become a 
future, if not an immediate, tax on the community 
and state. This brings up the question of either pro- 
hibiting marriages of defectives (known to be such 
through public charities or public institutions and 
hence not ascertained by the compulsory examination 
of private individuals), or of legal sterilization of 
such defectives. 



CHAPTER II 



VACCINE PREVENTION AND VACCINE 
THERAPY 



A brief survey of what has already been accom- 
plished shows that small-pox may be prevented, and 
that typhoid fever and paratyphoid fever may be pre- 
vented by vaccines. Streptococcic and staphylococcic 
infections may be prevented by vaccines, and perhaps 
pneumonia and erysipelas may soon be aborted, if 
not prevented, by vaccination. 

Vaccines will often aid in the cure of chronic tuber- 
culosis, of gonorrheal complications, of septic infec- 
tions, of erysipelas, and some cases of rheumatism, 
and will delay some tumor growths. Vaccine therapy, 
at times, seems to aid in curing typhoid fever, para- 
typhoid fever, and pneumonia. 

Antiserum cures diphtheria and cerebrospinal fever, 
and we trust some serum will soon be found for the 
cure of anterior poliomyelitis. Serum developed from 
the blood of syphilitics who have received injections 
of arsenic seems to be therapeutically valuable when 
introduced into the spinal canal of syphilitics suffer- 
ing from central nervous-system complications. 

It is a well-known pathologic fact that properly to 
combat a local infection by the blood-serum and in 
order that the necessary amount of detoxicating anti- 
bodies may form, the region about the infection must 
become congested, that is, the blood-flow, though per- 
haps decreased in rapidity must be increased in 
amount. Hence, it has been suggested that before 
the administration of vaccines in chronic localized 
infections or suppurations, means should be taken, 
physically or by drugs, to cause hyperemia of the 



SMALLPOX 41 

part or parts affected. For instance, if the infection 
is in the skin or near the surface of the body, arsenic 
or thyroid may be given, or body heat, body-baking, 
hot baths, or hot applications may be used. If the 
circulation is sluggish in an inflamed mucous mem- 
brane in the nose, throat, or bronchial tubes, 
ammonium chlorid or digitalis might greatly benefit 
the action of the vaccines. 

SMALL-POX 

Vaccination as a protection against this serious dis- 
ease has been long confirmed by history. Germany, 
the most effectively protected country in the world 
against small-pox, compels vaccination at the age of 
1 year, and again at the age of 12. With a popula- 
tion of sixty-five millions in 1913 there were only 
seven cases of small-pox and no deaths. 

Some careful observations on vaccinations against 
small-pox have been made by Force^ which it is well 
to review. 

One good method is to cleanse the arm or leg with 
ether or alcohol, then to remove the epidermis in three 
small spots, by some such scarifier as a dental scaling 
chisel, by rotary motion, as recommended by Force. 
He scarifies each spot about 2 mm. in diameter, then 
applies a drop of glycerinated virus thinly spread. 
The amount carried on the broad tip of a sterilized 
wooden tooth-pick is sufficient for the three spots. 
When this glycerinated virus has dried he covers it 
with a layer of gauze held by narrow strips of adhe- 
sive plaster, not allowing the adhesive plaster to pass 
over the treated areas. The patient is told to return 
in five days, and the areas involved being small, no 
bad arm could develop. No ointments or antiseptic 
dressings are allowed. If soreness develops, an alco- 
holic wet dressing is used, one part of alcohol to two 
parts of water (or even half and half), and soon the 

1. Force, John Nivison: An Investigation of the Causes of Failure 
in Cow-Pox Vaccination, The Journal A. M. A., May 9, 1914, p. 1466. 



42 REVACCINATION 

inflammation will subside. On the tenth day anti- 
bodies should arrest the growth of the vaccine organ- 
isms and immunity should be established. 

Cross scarification is said to be prohibited in Ger- 
many, as it is said "to favor the growth of anaerobic 
bacteria," and deep, unsightly scars are the result 
(Force). 

A good take is shown in five days by "a yellowish 
vesicle surrounded by a narrow red areola." This is 
vaccinia, or a primary take, while a vaccinoid or sec- 
ondary take shows in five days "a smaller vesicle sur- 
rounded by a wider areola." "When no vesicle 
develops and the areola appears and subsides early, 
it is an immediate reaction, first described by Jenner 
as 'sudden efflorescence.' " 

If a revaccination is made in a person with a 
seven-year-old, or older, scar, he may be vaccinated 
in two spots with a control spot inoculated with 
glycerin only. "If either of the two vaccinated spots 
showed an areola of 5 mm. or over (with or without 
a papule) at the end of twenty-four hours, which are- 
ola (or papule) had decreased after seventy- two hours 
following vaccination (observations after each twenty- 
four hours) it was considered a reaction of immunity. 
. . . If either of the vaccinated spots showed an 
areola at the end of twenty- four hours which devel- 
oped into a small vesicle, maturing on the fifth or 
sixth day and then rapidly subsiding, the reaction was 
considered a vaccinoid. If there was no change until 
the third day and then a small areola began to form, 
the case would be vaccinia." A small number of 
unvaccinated persons with no history of small-pox 
showed the reaction of immunity in this investigation 
by Force. Force and his co-workers believe that in 
these cases of apparent immunity without scar, pre- 
vious vaccinations had been unsuccessful so far as 
typical sore and subsequent scar is concerned, but 
sufficiently successful to cause subsequent immunity. 



TYPHOID VACCINATION 43 

If there is no reaction of any kind, Force thinks that 
the vaccine used is inert. 

The caution is given to observe daily the vaccinated 
area in all doubtful cases, as immunity reactions are 
soon over, and revaccination may be done unneces- 
sarily. 

The question of the vaccination pustule is worthy 
of careful consideration. Dyer^ states that the vac- 
cine vesicle is just as much an indication of vaccinia 
as the hard chancre is that a patient has syphilis. He 
also states that the vaccination injury should stop 
at the vesicle, that the pustule is only a sign of a 
local infection, and hence should be prevented. There- 
fore, he advises breaking the vesicle and treating the 
vesicular lesion antiseptically, and suppuration will 
thus be prevented. Such a method prevents gland- 
ular enlargements, erythemas and other eruptions. 

Dyer also urges, as soon as the vaccine vesicle has 
healed, revaccination to ascertain if the patient is 
thoroughly protected, and he would revaccinate as 
long as a vesicle will form, and would not wait a 
number of years before such a trial. He believes a 
patient thus treated is positively protected against 
small-pox. 

VACCINATION AGAINST TYPHOID FEVER 

The importance of the prevention of this disease 
is self-evident when it is stated that about 500,000 
people are attacked by it and more than 35,000 deaths 
occur from it annually. Of these about 150,000 cases 
occur and about 25,000 die of it annually in the United 
States. The economic loss from expenses due to ill- 
ness and to the loss of productive lives is simply 
enormous, and is stated by economists to represent, 
in the United States alone, a financial loss of about 
300 million dollars a year. 

The usual mortality of typhoid fever is about 10 
per cent., while the protection from the recurrence of 

2. Dyer: Am. Jour. Trop. Dis. and Prev. Med., 1913, 1, 447. 



44 CAUSES OF, TYPHOID 

typhoid, the patient having once survived it, is repre- 
sented by more than 95 per cent.; that is, less than 
5 per cent, of persons attacked have a recurrence. 

The most frequent cause of typhoid fever is infected 
water and infected milk. Washing uncooked vege- 
tables and fruit with infected water may also more 
or less frequently cause the disease. As long ago as 
1894 it was shown that oysters could become con- 
taminated with water which received infected sewage, 
and when served uncooked could cause typhoid fever. 
The culpability of oysters under such conditions has 
been shown frequently, although some bacteriologic 
investigations indicate that the pathogenic bacteria 
from the human intestinal canal are rarely found in 
oysters. It has been demonstrated beyond contro- 
versy, however, that oysters fattened in fresh-water 
polluted streams may harbor pathogenic germs and, 
when served uncooked, transmit them to the hum.an 
being. As it has been shown that oysters do not feed 
much in cold weather, the danger from their con- 
tamination in the cold months is less than in the warm 
months. Also, the danger of oysters becoming infected 
has been diminished by the decree by most boards of 
health that oysters must not be deposited in fresh 
water for fattening or in water near the shore that 
readily becomes contaminated with sewage. 

For a long time it was not satisfactorily proved that 
round clams could become infected with typhoid 
bacilli. Hence the "little necks" have long been eaten 
raw by those who refused to eat raw oysters. It has 
been shown lately, however, that round clams may be 
suspiciously contaminated with sewage germs, although 
no positive decision that cases of typhoid have ema- 
nated from eating such raw clams is known. Long, 
soft-shelled clams are almost invariably eaten cooked, 
hence the danger of contamination from such shellfish 
is at a minimum. 

Another source of danger from typhoid fever is that 
due to flies. These may carry on their feet typhoid 



PREVENTION OF TYPHOID 45 

as well as other germs and deposit them on foodstuffs 
in markets, in kitchens, and on the dining table. Con- 
sequently, flies are a serious menace to the health of 
a community. Possibly the greatest number of cases 
of typhoid fever occur in the early fall months because 
this is directly after the greatest fly period. Ninety- 
five per cent, of flies are born in manure heaps ; there- 
fore the most important method of exterminating the 
fly pest is to prevent their growth in manure heaps. 
The United States Department of Agriculture, in 
Bulletin ii8 states that a small amount of borax 
sprinkled daily on horse manure will prevent flies 
from breeding. 

Borax should also be sprinkled over garbage (espe- 
cially when not intended for feeding to pigs), over 
all refuse heaps and open toilets, and it may be 
sprinkled on the floors of markets. While borax will 
not kill the grown fly, it will prevent fly eggs from 
hatching. The cost of borax in Washington is between 
5 and 6 cents per pound in 100 pound lots, and it is 
estimated that it would cost only 1 cent a day per horse 
for the borax treatment of stables. 

Contaminated dust may infect food, and may occa- 
sionally be a cause of this disease. 

Although the germ of typhoid fever always ema- 
nates from the discharges of persons sick with the 
disease, the danger from carriers who may for years 
continue to produce the living germs must never be 
forgotten. Therefore, every sewage system and every 
privy vault is open to suspicion. The water at sea- 
shores, or even fresh water not protected from con- 
tamination, should not be swallowed or taken into the 
mouth by bathers. Sanitary privies should be rapidly 
introduced, and when this is not immediately possible, 
means of killing the germs in human fecal matter 
should be constantly used. All toilets and privies 
should be screened from flies, and any stable or barn 
where milk is handled should be under suspicion if the 
place is dirty, dusty, and fly-infested. All foods should 



46 TYPHOID IN ARMIES 

be under suspicion if exposed to dust and flies. The 
purification of water-supplies is a question for state 
and municipal boards of health, and failure on their 
part to supply to all communities pure, clean water 
is open to the criticism of negligence and incom- 
petency. Great improvement, however, is being made 
in many communities in these respects. 

In 1893, Frankel first published his observations on 
the inoculation treatment of typhoid fever. In 1896, 
Wright published his first article on antityphoid inocu- 
lation. The British first introduced inoculation in the 
Indian army for the prevention of typhoid fever and 
demonstrated that the individual was protected by such 
inoculation for two and one-half years, and partially 
immunized for five years. In 1900, inoculation pre- 
vention was used by Germany, also, in her armies, and 
German and English military camps soon became 
almost free from typhoid fever by such protective 
vaccination. 

The danger to an army from typhoid fever, espe- 
cially during war times, when it is encamped in regions 
not previously equipped to care for large numbers of 
men in a sanitary manner, is well shown by the state- 
ment that one-fifth of the soldiers in a national 
encampment of our men in the Spanish- American war 
had typhoid fever, the actual figures being that out of 
107,973 men, 20,728 had typhoid fever, of which num- 
ber 1,580 died. It is also stated that in 90 per cent, 
of the volunteer regiments the disease broke out 
within eight weeks after going into camp. 

In spite of all sanitary measures possible, typhoid 
fever will prevail until the preventive vaccination is 
inaugurated. With the inauguration of this measure 
in the United States Army typhoid fever became 
greatly diminished in frequency. Vaccination of our 
army was begun in 1909, and, in 1911, among 80,000 
men only 11 cases of typhoid fever occurred, with one 
death. In 1912 there were 15 cases in the army, with 
2 deaths. This shows that occasionally the typhoid 



INCUBATION PERIOD 47 

inoculation does not protect, but the improvement 
shown by the diminution in the number of typhoid 
cases from 9.43 cases out of every thousand soldiers 
in 1901, to 0.26 for every thousand soldiers, in 1912, 
compels belief in its efficiency. The death-rate from 
this disease decreased, per thousand soldiers from 
0.64 in 1901 to 0.03 in 1912.^ 

The incubation period of typhoid fever is about two 
weeks. Its duration, when there are no relapses, is 
about two months. This means two weeks of incu- 
bation, four weeks of more or less serious illness, and 
two weeks before the real convalescence. Young 
adults and youth are most likely to contract this dis- 
ease, although it may occur at any age. This is the 
age, then, for the greatest effort to be made to give 
protective inoculations. All nurses and members of 
hospital staffs; students of colleges and seminaries; 
employees, and those who are interned in work houses, 
jails, prisons and asylums ; men in lumber camps ; and 
all those who travel and are therefore subjected to 
varying water, milk and food-supplies, such as "travel- 
ing" men, engineers, seamen, tourists, and vacationists, 
should receive typhoid preventive vaccination. 

While it has been asserted that immunity is more 
positively conferred for a long period by vaccination 
with living bacteria (protection being similar to that 
produced by an attack of typhoid fever) still it is gen- 
erally considered safest and best to vaccinate with 
dead bacteria. The vaccine slowly stimulates the pro- 
duction of antibodies, that is, in from five to eleven 
days, with an average of eight days. Some time later 
there is an increase in the opsonins and agglutinins. 
The blood generally shows the Widal reaction after 
the third inoculation. One case was found negative.^ 

3. Russell, F. F. : House of Representatives Document 1404, Feb. 
19, 1913. 

4. Maverick, Augustus: Typhoid Vaccination and the Widal Reac- 
tion, The Journal A. M. A., June 1, 1912, p. 1672. 



48 CONTRA-INDICATIONS 

Though it has been denied, it seems to be a fact that 
typhoid vaccine can cause a reaction similar to tuber- 
culin in those infected with tuberculosis. 

It has been shown that there is a skin typhoid 
reaction test similar to the von Pirquet tuberculosis 
skin test. Gay and Force found this test positive in 
20 cases out of 21 (95 per cent.) patients who had 
recovered from typhoid fever. The same test was 
negative in 85 per cent, of 41 cases who had not had 
typhoid fever. This method may become valuable as 
a test for the continuation of typhoid immunity after 
typhoid inoculation.^ 

With all the advantages to an individual and to a 
community conferred by protection against typhoid 
fever by vaccination, the physician must also carefully 
consider what constitutes contra-indications. It seems 
to be wise carefully to examine every individual to 
ascertain his condition of health before vaccination is 
done. It should not be done if he is suffering from 
any acute infection however simple, namely, a coryza, 
a pharyngitis, a tonsillitis, or any acute gastro-intes- 
tinal disturbance, gonorrhea, syphilis, albuminuria, 
glycosuria, or the more serious conditions of chronic 
nephritis or diabetes. The injections should be made 
in the afternoon, and the active symptoms will gen- 
erally be gone by noon of the next day. Three injec- 
tions should be given at weekly intervals. 

There is a systemic reaction in about 7 per cent, 
of the cases, most frequently after the second dose, 
next in frequency after the first dose, and least fre- 
quently after the third injection. The temperature 
reaction varies, with an averalge of about 100 F., asso- 
ciated with malaise, rarely diarrhea and some nervous- 
ness and sleeplessness. Sometimes erythemas occur, 
and occasionally a herpes of the lips. Generally all 
active symptoms have disappeared in forty-eight hours. 
Every person inoculated with this vaccine should 

5. The technic of this test will be found in Arch, Int. Med., March 
15, 1914, p. 473. 



METHOD OF INJECTION 49 

avoid alcohol and all stimulants, should not eat meat, 
should keep out of the sun, and should not take much 
exercise. While in the army the vaccinated men were 
alloAved to do ordinary work, in private practice it 
is inadvisable to allow any exercise during a real reac- 
tion. If there is no reaction, the inoculated indi- 
vidual may do ordinary work on the following day. 

It has been shown that paratyphoid fever may also 
be prevented by vaccination with the paratyphoid 
germs. It seems wise, therefore, in vaccinating 
against typhoid, to vaccinate with the combined vac- 
cine of typhoid and paratyphoid. The ordinary adult 
doses for injection are as follows : The first dose may 
contain 500 millions of the killed typhoid bacilli, 250 
millions of the killed "A" paratyphoid bacilli, and 250 
millions of the killed *'B" paratyphoid bacilli. The 
ordinary second dose is double this number of dead 
bacteria, respectively (1,000 millions of killed typhoid 
bacilli, 500 millions of killed "A" and 500 millions of 
killed "B" paratyphoid bacilli). The third injection 
represents the same number of killed bacilli as the 
second injection. 

The method of injection is as follows: Paint with 
tincture of iodin an area about 15 mm. in diameter at 
the insertion of the deltoid muscle. Inject subcutane- 
ously with sterile needles and the best vaccine the dose 
of killed bacteria decided on. Then paint the region 
with collodion and allow it to dry. If proper care 
is taken, no infection will occur, and, as above stated, 
a temperature reaction is rarely above 100 F., and 
perhaps never reaches as much as 102 F., even in 
exceptional instances. A severe reaction could only 
occur when there is some serious complication in the 
individual, as perhaps tuberculosis. All slight reac- 
tions are generally over in twelve hours and even 
severe ones are generally over in twenty- four hours. 

The local reaction is greatest after the first dose, 
less after the second, and least after the third. 
Typically, there is an acutely inflamed area, varying 



50 VACCINATION AS TREATMENT 

in size, not hard and indurated like an incipient 
abscess. The arm may ache, and the axillary glands 
may become tender. The local reaction is generally 
at its height in about ten hours, and generally nearly 
gone in twenty-four hours. Any more severe reaction 
would be due to contamination. 

The dosage for children should be based on the 
child's weight and not on its age. The recommended 
adult dose is based on a weight of 150 pounds. It 
seems to be necessary for continued protection to 
revaccinate children more frequently than adults, 
namely in about three years. The skin test above 
referred to may become a means of ascertaining 
whether, or not, the individual is still protected. It 
should be remembered that almost one-third of all 
typhoid deaths occur in persons under 20 years of age. 

Typhoid vaccination as a treatment during the 
course of typhoid fever has not been much used. The 
theory against such vaccination is that it has seemed 
unwise, in any disease, to vaccinate and to stimulate 
an acute process, it being considered that the indi- 
vidual is utilizing all of his combative powers in fight- 
ing the infection that he already has. We must note, 
however, that cases are beginning to be placed on 
record in which it seems that relapses are prevented 
and that post-typhoid complications such as typhoid 
infection of the ears, kidneys, gall-bladder, etc., may 
be prevented by the judicious use of an antityphoid 
vaccine. Hospitals, which are the best prepared to 
carefully watch and judge of the advantages con- 
ferred by these injections, should investigate this sub- 
ject. Until statistics are available, it may be well not 
to inject these bacilli until such time as the patient 
is shown to be a typhoid carrier. It is stated that 
stock vaccines in these instances are as valuable in 
preventing relapses as are autogenous vaccines. 

About 4 per cent, of typhoid-cured patients become 
chronic carriers. As above urged, a most serious 
danger to any community is a typhoid carrier, and 



TREATMENT OF CARRIERS 51 

unfortunately it is difficult to discover such. As pre- 
vention is here also greater than cure, it is a question 
for the board of health to decide when a typhoid 
patient shall be released from quarantine, that is, 
allowed to deposit his urinary and fecal excretions 
in the sewers or privies without disinfection. Also 
a carrier may contaminate his hands with living 
typhoid bacilli, and thus spread the disease. This 
probably means that the feces and urine should be 
repeatedly examined by the board of health until 
typhoid bacilli are found to be absent. This would 
be a difficult problem, and would interfere more or 
less with individual freedom, but from an economic 
standpoint it would be the most money, health and 
life-saving work that a board of health could inaugu- 
rate. 

A chronic typhoid bacillus carrier having been dis- 
covered (and such are only discovered by the attend- 
ing physicians, hospitals, and boards of health being 
ever alert), he or she should be isolated and treated. 
Hexamethylenamin may cure a kidney infected with 
typhoid germs. Typhoid bacilli vaccines seem to offer 
the most successful treatment of these typhoid car- 
riers. Whether they are best treated with stock vac- 
cines or with autogenous vaccines is yet to be deter- 
mined. Also, the frequency with which such cases are 
cured is not yet decided. If operative interference 
would remove the infection, it should be advised. This 
is especially true in cases in which either the gall- 
bladder or the ear is the suspected source of infection. 



CHAPTER III 



THE SCHOOL QUESTION 



The following are a few suggestions of important 
subjects that medical men should impress privately 
on their families and publicly in their communities: 

1. A child should be healthy before it goes to school 
(adenoids, tonsils, teeth, anemia, debility, etc.). 

2. The kindergarten methods of teaching should be 
investigated, as some parts of this teaching are 
objectionable, and especially should the eyes of these 
young children not be overtaxed. 

3. The best age for a child to attend a kindergarten 
is from 4 to 6 years; but the ordinary child at 6 
years of age is too young to enter real school work. 
It would be ideal, from a physical point of view, if 
the child could then have one year, or in some 
instances two, in a "play school," combining physical 
exercise with moral and mental development. Then 
the child would be well fitted to attend real school. 

4. The location of school buildings is important, 
and the architecture and equipment of such buildings 
are very important. 

5. There should be well-equipped playgrounds in 
all cities. 

6. The books, pencils and other school para- 
phernalia should be antiseptically cleaned, and clean 
aprons could well be provided for dirty kindergarten 
children. 

7. Teachers should be mentally efficient, and should 
be physically examined at regular intervals as to their 
health. A physically and mentally "fit" teacher is 
essential for good school work. 



SCHOOLHOUSES 53 

8. Open air or open-window schools, and luncheons 
for underfed children should be inaugurated. 

9. Kissing and the exchange of pencils and pen- 
holders among children should be discouraged. 

10. There should be a trained nurse attached to 
each large school. 

11. There must be medical inspection, if not med- 
ical examinations. 

12. There should be segregation for feeble-minded, 
as well as for otherwise defective children. Anemic 
children, and those with a tuberculous tendency should 
be in open air rooms. 

13. Night schools should have medical and sani- 
tary supervision, especially if such schools are held 
in the rooms occupied by the children in the daytime. 

14. The crime of child labor should be prevented. 

SCHOOLHOUSES 

The location of the city school cannot always be 
carefully selected; the school must be placed where 
it is most needed. The country school, however, 
should be located high and dry, and with a careful 
consideration of its sanitation, that is, its water-supply 
and the proper management of its sewerage system. 

There is no excuse for having a country school 
more than two stories, and if possible, a city school 
should be but two stories high. The frequent going 
up and down of long flights of stairs is especially 
bad for growing girls. The light should be sufficient, 
and should not shine directly into the pupils* eyes, 
but should best enter the room from the left and 
the rear. The blackboards should be so placed as 
to receive the best light. The temperature should 
be from 65 to 68 F. Moisture should be sufficient, 
but not excessive. 

The desks and chairs should be very carefully 
selected, and one or both should be adjustable as to 
height. Even with such adjustment the children 



54 HOURS IN SCHOOL 

should not be kept too long sitting, but should have 
walking, or simple calisthenic exercises to stimulate 
the circulation and ease the muscles. 

The floors should be hard finished, so that they 
may be readily cleaned with vacuum cleaners, and 
the furniture should be such that it can be readily 
cleansed with antiseptics, when such are needed. In 
fact, daily washing of the floors with some antiseptic 
may be advisable. The toilet and washing arrange- 
ments should be of the best, and sanitary drinking 
facilities should be installed in every school. 

Some one or more rooms should be arranged as 
open-window rooms. Every large school should have 
a private examining room for the use of the exam- 
ining physician and the trained nurse. Every school, 
if possible, should have a properly equipped play- 
ground. 

HOURS IN SCHOOL 

The kindergarten is undoubtedly good for children 
whose mothers cannot care for them and who 
otherwise would be on the street, but the kindergarten 
teaching is often bad for children who are already 
pushed mentally in their own homes. We are not 
sufficiently careful to prevent mental fatigue in school- 
children, and the number of hours generally devoted 
to school work is much too great. R. O. Clock^ has 
studied this subject, and makes suggestions which 
should be carefully considered. He believes that 
from 7 to 8 years of age two hours of actual school 
mental work is sufficient; from 8 to 9, two and one- 
half hours; from 9 to 10, three hours; from 10 to 
12, four hours ; from 12 to 14, five hours. The longer 
periods should, of course, be broken up into two ses- 
sions. At all ages the sessions should be interrupted 
with from fifteen to thirty minutes' recess for fresh 
air and relaxation. It has been ascertained that a 
child at 6 has brain fatigue and his attention tires 

1. Clock, R. O.: Dietet. and Hyg. Gaz., September, 1912. 



OUTDOOR EXERCISE 55 

after fifteen minutes of concentration; from 7 to 10, 
after twenty minutes of concentration; from 10 to 
12, after twenty-five minutes of severe work; and 
from 12 to 16 after thirty minutes. The best brain 
work has been found to be accomplished in the morn- 
ing, and fatigue is more rapid in the afternoon, and 
more rapid when there are bad air and dark or over- 
heated rooms. The brain activity is increased after 
gentle muscle exercise; hence the advantages of 
calisthenics and recesses. 

It is little less than a crime to spur on brain work 
without proper exercise and outdoor play, and some 
pupils, little more than children, are stimulated to 
mental overactivity and to attain high standing with- 
out regard to whether or not they have time for 
fresh air. Before the age of 12 years a child should 
not be required to study at home. The crime of 
pushing children forward, rushing their advance from 
one grade to another, should cease. The child should 
advance by natural ability and natural progress. 
Cramming and pushing to get a certain amount into 
his brain at a certain date, and then to get him out 
of his grade into another to make room for one who 
is being pushed and crammed in the grade below 
should be abolished. 

OUTDOOR EXERCISE 

Playgrounds, and regular hours for their use, and 
the occasional presence and direction of games or 
exercises by a physical instructor, all work for the 
great good of the future sturdy citizen. 

Weak children should not be allowed to play or 
exercise to exhaustion. Also, even with strong chil- 
dren, the necessity for bodily repair by rest periods 
should be urged. The story of nutrition, metabolism 
and elimination of waste products, and the repair dur- 
ing rest should be understood by all teachers. The 
bedtime hour for children of diflferent ages should be 
taught by the teachers. 



56 PHYSICAL EXAMINATION 

Competitive physical, and even mental tests or 
stunts are bad, very bad for some. It is always injuri- 
ous for growing boys and girls to sustain long physical 
strain, and it should not be allowed by school boards 
in schoolchildren. This does not mean that under 
proper jurisdiction there should not be baseball games 
for boys and basketball games for girls, etc., but 
competitive stunts, as just stated, should not be 
allowed. Secret societies which cause jealousies and 
cliques and ill feelings should not be allowed, although 
certain open, non-secret societies whose membership 
is reached by good work and whose object is to 
accomplish good work are often excellent training. 

PHYSICAL EXAMINATION AND PHYSICAL EXERCISE 

When it is remembered that there are twenty mil- 
lion pupils in the public schools, large percentages (as 
previously stated) being defective in some form or 
other, it will not be surprising that the following 
recommendations for the physical examination of chil- 
dren, as distinct from medical inspection which will 
be discussed later, is urged. These recommendations 
seem more or less ideal, but they will come to be the 
rule, if not the law, nevertheless. 

If it is agreed, as advanced by some thoughtful 
educators and physicians, that from the age of 6 to 
8 the time should be devoted to physical culture 
directed by the public schools, and that book work 
should not begin until the age of 8, just what would 
be the method of procedure? 

First, no sick child should be allowed in the public 
schools, whatever the age, and sick children should 
be immediately sent home to the care of their parents. 
Every child on entering the public school, we will 
say at the age of 6, should be carefully examined by 
a skilled physician. This is more than "medical 
inspection," which only seeks for contagious or trans- 
mittable diseases. The record of each child should be 
kept on a large card suitable for filing alphabetically. 



RECORDS 57 

One side of the card should be filled out by the teacher 
with such data as name, residence, age, sex, nation- 
ality, height, weight; condition of parents (living or 
dead, and health), brothers and sisters (number and 
health) ; what diseases the child has had, besides a 
record of fits, headaches, asthma, hay fever, bilious 
attacks or attacks of abdominal pain (information on 
these subjects should be obtained from the parents by 
the teacher) ; the number of rooms in the tenement 
or house of the family, the number of windows in 
the sleeping room of the child, the number of persons 
sleeping in this room; and the kind of food and drink 
the child receives (question of coflfee, tea, etc.). 

On the reverse side of this card the physician 
should note the condition of the hearing, the eye- 
sight and the teeth; defects in the palate; condition 
of the tonsils, question of adenoids, mouth breathing, 
condition of the nose, and of the glands of the neck; 
the shape of the chest and abdomen; any defects of 
the spine, legs and feet ; and the condition of the lungs, 
heart and abdominal organs. If there is bed-wetting 
it should be recorded, and in such cases the condition 
of the prepuce noted by the physician, or the con- 
dition of the clitoris noted by the trained nurse. If 
there is suspicion of kidney disturbance the urine 
should be examined. If the child appears anemic the 
blood should be examined. A general statement of 
the state of health and nutrition, and the condition 
of the skin should be noted ; also the medical opinion 
of the development of the child up to the present 
time. The disposition of the case should also be 
stated, that is, what advice was given. The card 
should be carefully dated. Subsequent examinations 
should be on a separate card, which should be clamped 
to the original. 

The results of the foregoing examination should 
determine the proper treatment, if any treatment is 
needed, and should determine the instructions that 
should be given the parents as to the need of seeking 



58 HOME HYGIENE 

the advice of their family physician or of consulting 
a specialist. Also, the outcome of this examination 
would disclose the need, or not, of special physical 
exercises to correct beginning deformities. AH chil- 
dren deemed able should then be taught by a physical 
teacher the physical culture exercises deemed wise 
for children of this age; one hour a day of various 
exercises under instruction as classes, and another 
hour in the school playground. The physical teacher 
should devote two or more hours a day teaching and 
treating children with physical defects. 

All of this requires money, but to what better 
object could public money be devoted than to building 
up the physique of our children and to prevent future 
defectives and future disease? 

At 8 years of age the child is physically and men- 
tally ready for regular school work (not too many 
hours, or too much home study, as previously cau- 
tioned). Such children on growing up keep the habit 
of exercise, thus acquired, to their benefit, as they 
will live in the age of labor-saving devices and work 
that requires but little muscular effort. 

Bad home food and bad home and house hygiene 
would be corrected as far as possible by the visiting 
nurse, who can be the trained nurse attached to each 
large public school. Again, all this costs money and 
seems ideal, but such an outlay would pay the com- 
munity good dividends on the investment by raising 
healthy citizens and in preventing disease. Some 
of this cost could be offset by not appointing so many 
teachers of things that are not essential and devoting 
more time to the groundwork of education. 

To repeat, it should be urged to push only the essen- 
tial studies, and curtail or cut out non-essentials and 
trimmings. Later, both boys and girls, but the latter 
especially, should be instructed in bacteriology and 
physiology and hygiene. Much valuable information 
may be given by the picture method of illustrating the 
causes of disease, etc. 



MENTAL DEFECT 59 

It IS not advised to pauperize the people by devel- 
oping or using too many unneeded free dispensaries. 
Let all parents, unless they are positively unable, take 
their defective children to physicians, surgeons a/nd 
dentists of their own selection. Of course provision 
must be made for those children whose parents can- 
not pay for such services; but let the visiting nurse 
make this decision. 

As the children grow older they should be taught 
how to walk, and dancing exercises of the supervised 
type might be a part of the physical culture. 

When the child is 8 years of age and begins the 
regular school work, its mental condition should be 
noted, unless it has been previously declared *'feeble- 
minded." Those who are "feeble-minded" should be 
segregated and taught separately from the bright 
children, and an entirely different course and entirely 
different future plans of educational work should be 
outlined for such children, distinct from the regular 
course of instruction for the normal children. 

It is an economic mistake not to separate mentally 
defective children from normal children. Three years 
ago it was estimated that there were three million 
children in the United States repeating a school grade 
a second, third, or even a fourth time at a cost of 
a hundred million dollars annually to the country, a 
needless and wasteful expense.^ It is declared that 
the mental capacity of an idiot at any age does not 
exceed that of a child of 2 years ; that of an imbecile 
of any age does not exceed that of a normal child 
of 8; and that of a feeble-minded person of any age 
may range from the normal mental capacity of a 
child from 8 to 13, but never exceeds the 13-year limit. 
These figures emphasize the necessity of the segre- 
gation of feeble-minded children, and also the crime 
of punishing for indifference or delinquency these 
children, who are doing all they can do. 



2. Report of Committee on Medical Inspection of Schools, The 
Journal A. M. A., Nov. 25, 1911, p. 1753. 



60 TEACHING OF HYGIENE 

The frequency of the physical examinations must, 
of course, depend on the findings in each case. 
Defective children should be examined, at least as 
to the condition of the defect first found, once in 
three, six or twelve months, depending on the kind 
of defect. The results, for instance in adenoid or 
anemic children, should be certified to by the trained 
nurse on the reverse side of the child's card; that is, 
whether or not operation has been done in the one 
case, or whether the child is improved or otherwise 
in the other case, the child, supposedly, being under 
the care of the family surgeon or physician. 

All of this is paternalism, but only thus is the good 
of the greatest number accomplished, and no person 
should be allowed to cause himself to become a tax 
on the community, to spread disease, or to break well- 
known laws of health and hygiene. 

As the child grows older, as suggested above, he 
should be taught general hygiene, the laws of con- 
tagion, and the ordinary methods of communicating 
each disease, and simple rules of prevention. Simple 
anatomy and simple physiology, and the simplest kind 
of life problems should be taught in public schools. 
Sex hygiene should not be taught to mixed classes 
or much in mixed schools. The girls, at or before 
maturing age, should be instructed in such hygiene 
individually, not in classes, by the trained nurse. The 
boys may be talked to by the principal of the school 
in small groups confidentially, not from the platform. 

It is necessary to urge the foregoing physical exam- 
ination because of the twenty million children attend- 
ing public schools in the United States only about 
two-fifths have more or less efficient school inspec- 
tion and only a very few have medical examinations, 
and the muscle strength and physical development of 
our people is said to be deteriorating. 

It should be urged that good able physical instruc- 
tors must be obtained, or serious mistakes are liable 
to be made. After 10 years of age it is very doubt- 



CARE OF NERVOUSNESS 61 

ful if the games and exercises played or taken by boys 
should be as strenuous for girls ; but it has been shown 
by some careful observers that girls are not harmed 
by ordinary exercises while menstruating. In fact, 
it is a serious error for a girl or her mother to 
believe that she must be an invalid for one or two days 
every time she menstruates, and a young ladies' 
seminary that puts each girl to bed for a day at each 
menstrual epoch does a serious mental injury to the 
girls. On the other hand, it is not advisable to cause 
these growing, maturing girls to climb stairs all day 
in a schoolhouse. 

Chronically nervous children, and certainly the epi- 
leptics, should be sent home until cured (if cure is 
possible), or given an entirely different kind of school- 
ing, away from large numbers and the shame caused 
by the publicity of their defects. Open-window or 
outdoor schools with small numbers of pupils and 
individual teaching, and scientific medical psycho- 
pathic decision of the best management to overcome 
such nervous defects as stage fright, stammering, 
weeping, brain storms, etc., should be the course fol- 
lowed with such children. The regular teachers, 
underpaid and overworked, should not be made 
responsible for the instruction or welfare of these 
children. 

The only treatment for developed chorea is rest in 
bed; if the case is not severe, open air treatment in 
the country or at the seashore is essential, best where 
it is warm, and where the child can be under the care 
of one well-balanced person. Books, and playing with 
other children should generally not be allowed. Paren- 
thetically, it might be mentioned that rheumatic germs 
should be suspected, and all disease from tonsils, 
adenoids, teeth and gums eradicated. 

Mental fatigue (with good judgment as to hours of 
confinement and study and of intermittent play and 
exercise periods) should rarely occur, except in the 
nervous or neuropathic or otherwise diseased child. 



62 MEDICAL INSPECTION 

Precociousness and the morbid desire to overstudy 
is a sign of mental unhealth, and such children should 
be restricted in their book work and be compelled 
to do more physical work. If such management is 
not successful, they should be treated as psychopathic 
and as nervous children. 

It may be briefly suggested here that adenoids, 
which are so frequent in young children, tend to 
shrink by the age of 14 or 15; but the teacher may 
readily observe, without medical examination, that 
a child is a mouth breather, looks dull and stupid, that 
there is beginning deafness, that the speech is imper- 
fect, and that the chest expansion is incomplete. 
Mouth breathing interferes with the growth of the 
face and nose. 

About 1 per cent, of children have discharging ears, 
and such ears may carry infection. Hence both for 
the child's sake and for the sake of others a dis- 
charging ear should be treated by an expert. 

Eye-strain is of frequent occurrence in children, 
and headaches, granular lids, twitching of the lid 
muscles, and disturbances due to imperfect eyesight 
should be ever watched for by the teacher. Much 
absence from school, much loss of appetite, much ner- 
vousness, and much inability to study properly and 
advance are due to eye defects, a large proportion of 
which may be corrected. 

MEDICAL INSPECTION OF SCHOOLCHILDREN 

The importance of this subject is evident when it 
is estimated that 70 per cent, of deaths in the United 
States are due to contagion, that the vast majority 
of such contagion originates in schools and that, annu- 
ally, about 11,000 die of scarlet fever, about 10,000 
of whooping-cough, and about 9,000 of measles. 

Some considerations in the prevention of disease 
acquired in school are as follows: 

It is estimated that each pupil should have 15 
square feet of floor space and 200 cubic feet of air 



SANITARY MEASURES 63 

space. Each schoolroom should be about 30 feet 
long, 25 feet wide, and 13 feet high, and should 
accommodate not more than fifty children. Allport 
states that the temperature should be about 68 F., 
and the humidity between 60 and 70. The ther- 
mometer should hang where it will tell the truth, 
and the best region with this object in view is on a 
bracket on the inner wall about 4 feet from the floor. 

The sanitary measures require proper plumbing, 
proper drinking facilities, proper towels, sterilization 
of pencils, books, etc., and antiseptic cleaning of 
schoolrooms. Safety requires good fire escapes and 
fire drills. 

Medical inspection was started systematically in 
Belgium, and is now being gradually adopted by many 
of the European countries and by a large number of 
the cities of the United States. Perhaps more than 
500 of our cities now require medical inspection. 
Such inspection has been shown to be a necessity and 
not a luxury. It has been shown that contagious 
diseases are more prevalent during the months when 
schools are in session than when there is vacation; 
therefore if civic and state governments compel the 
attendance of children at school, they are bound not 
to subject the pupils to an increased danger of dis- 
ease and death. Hence medical inspection should be 
required by state laws, and about half of the states 
have already passed such laws. It should not be 
left to the petty decision of towns or cities, although 
the larger cities have long been pioneers in this work. 

This article will not attempt to deal with the ques- 
tion of salaries or the best method of managing the 
work cooperatively with the boards of health and 
school boards. The medical inspectors should be 
selected for their ability and interest in such work, 
and should be paid adequately. Also, they should not 
be subject to removal by political changes, if their 
work is satisfactory. 

The results of the inspection for contagion or 
infection should be noted on a filing card, which 



64 THE MEDICAL INSPECTOR 

record should be filed separately from the cards 
previously described in the "physical examination," 
although a cross-reference on the physical examina- 
tion card should be made. Later, on this contagious 
card, there should be noted the results of treatment 
and the outcome of the case. 

It is not suggested or advised that there be two sets 
of medical men examining and inspecting in schools, 
but it is urged that the two kinds of work are dis- 
tinct, that the latter, medical inspection, is essential, 
and that as much of the former, physical examina- 
tions, should be undertaken as is possible. The work 
can be, at least in small districts, splendidly combined. 

The same care should be exercised by the medical 
inspector not to overstep his rights, but to refer all 
cases back to the parents and the family physician, 
as was urged in the physical examination discussion. 
The trained nurse of each school or each district 
should follow up each case of infection sufficiently 
to determine that the child is being properly cared 
for, and that the infection of others is prevented. 
In all cases in which a complete examination is desir- 
able the consent of the parents should be obtained 
beforehand. In all cases where any examinations of 
girls are made, the trained nurse should be present. 
A private examining room in each school will facilitate 
and minimize the objection to such examinations. 

A FEW SUGGESTIONS FOR THE MEDICAL INSPECTOR 

1. The medical inspector should note the vaccina- 
tion mark (present, absent, character). 

2. He should note skin eruptions. 

3. He should look for evidence of body or head lice. 

4. He should be on the lookout for trachoma 
(which in some regions is of frequent occurrence). 

5. The inspector should make a careful examina- 
tion of every child found by the teacher or trained 
nurse with eruption, sore throat, a suspicious cough, 
or fever. 



NUTRITION 65 

6. He should examine all other children who are 
in immediate contact with the one who is ill or is 
found to have a contagious disease. 

7. He should examine all other children who live 
in the same house as the one affected and who are 
attending school. 

8. He should cooperate with the board of health 
to determine when a cured child should return, and 
when suspects should be subjected to, and when they 
should be released from quarantine. 

9. When there is no physical examination of all 
children in a school as previously outlined, the inspec- 
tor should make as much of an examination of appar- 
ently unhealthy children as possible. The important 
objects to be determined are: the condition of the 
teeth, nose, throat, eyes, ears, spine, feet, ankles, 
glands, heart, lungs, nutrition, mental condition, etc. 

NUTRITION 

Medical inspection should really be medical super- 
vision at least with the aid of the trained nurse, and 
a great problem of child health and of prevention of 
disease is that of nutrition. Underfed children are 
in goodly numbers, as shown by such statistics as are 
available, and for such the question of the diet at 
home is important, especially the breakfast. The 
homes and diet of all ill-nourished children should be 
investigated by the trained nurse. The value of the 
school luncheon is unquestionable ; however, its advis- 
ability must be determined by each community, but 
the actually underfed children must in some manner 
be provided with good food. There is no possible 
excuse for compelling a child to study who is receiv- 
ing insufficient food. 

EYES 

A very large percentage of children of school age 
are found to have defective eyes. Such defects being 
discovered, how many receive the proper glasses, and 
then how many keep their glasses properly adjusted, 



66 EYES 

and how many have reexamination as often as they 
should (such examination should be once a year) 
to determine the changes that will occur ? It is readily 
seen that the eye question is a serious one. 

As many children as possible, who have been found 
to have defective eyes and eye-strain, should be sent 
by their parents to oculists of repute, and the dan- 
ger of consulting opticians and so-called optometrists 
and department store eye clerks should be explained 
on a printed slip issued by the board of health or the 
school board. This paper should also urge that the 
child have spectacles with large sized lenses and rigid, 
light weight, inexpensive frames. There is no other 
method to equip an astigmatic eye properly, especially 
in children. All other frames, for a child, are a 
delusion and a snare. If a family can afford it, 
''dress up" gold or gold-filled frames may be had as 
an extra pair. Each child with glasses should have 
a good case for them, and in all rough games the 
glasses should be taken off and deposited in these 
cases and the cases placed in a safe spot. This detail 
may seem superfluous, but it is all-important. 

If the visiting nurse ascertains that the parents are 
unable to pay for a skilled oculist's examination, or 
for the lenses, then the child should be sent to a 
regularly appointed oculist who receives a small 
salary for such services. Later the prescription for 
glasses should be taken to a regularly appointed opti- 
cian or one of several who have contracted at mini- 
mum rates for such cases. Dispensary service for 
determining the correct refraction of a child's eyes 
for his life work is unsatisfactory and generally 
unavoidably bad. A child had better have no glasses 
at all than to have incorrect ones. Neither should 
it be expected that the oculist can devote time and 
science, unpaid, to such a nerve-tiring work as deter- 
mining the proper glasses for children. They are 
willing to do emergency and eye disease work for 
the poor gratis, but eye refraction work should be 



TOBACCO— ALCOHOL ^1 

paid for. Why should a community demand that a 
child go to school and then demand that some member 
of the community, without pay, make the child fit 
to go to school? On the other hand, the correction 
of eye-strain in children not only causes them to 
learn with more ease, but prevents eye defects that 
may mean untold suffering for years after. The 
migraine sufferers will certify to the correctness of 
this statement. 

tobacco: alcohol 

There is no question that during the teaching of 
school hygiene, during the study of physiology in 
school, and during the brief description of the action 
of, and the antidotes to, the more common poisons, the 
baneful effects of tobacco and alcohol should be hon- 
estly shown. It is of no more advantage to disseminate 
lies in regard to these narcotics and habit-forming sub- 
stances than to teach any other branch of knowledge 
incorrectly. The truth is bad enough. 

It is inexcusable for parents to give young children 
alcohol, but it is not wise to teach children that because 
their parents occasionally partake of a glass of beer or 
wine, they are condemned to perdition physically and 
morally. The higher standards of communities and 
the proper supervision of all places that sell liquor 
that is to be drunk on the premises will soon make 
overdrinking unusual except in the diseased. The 
moderate use of alcohol by adults must for some time 
be a matter for individual decision. Youth and those 
under age should not take alcohol in any form, not 
even tinctures or caffein stimulants at the soda-water 
fountains. 

Much more serious for the many among our young 
boys and young men is the overuse of tobacco. Where 
one young man uses alcohol perhaps twenty use 
tobacco. Cigaret smoking in young boys is tolerated 
in some preparatory schools, and even in some public 
high schools. In fact, a large number of young men 



68 AIR CONTAMINATION 

under 21 years of age smoke excessively and to their 
detriment mentally and physically. 

The symptoms and signs of oversmoking, the 
impaired chest and lung development, the impaired 
heart action, the impaired nutrition, injured nerves and 
weakened muscles are all matters of medical knowl- 
edge. These vary only in degree in young boys who 
overuse tobacco, and are all more or less in evidence 
sooner or later. Emphatically, growing boys should 
not be allowed to smoke, even if their fathers and 
teachers do. 

AIR CONTAMINATION 

Normally the alveolar air of the lungs, that is, the 
air retained in the lungs for oxygen and carbon dioxid 
(CO2) exchange, contains about 5 per cent, of the 
latter. If the amount of this gas in the retained air 
is diminished below 5 per cent., breathing is slowed 
until the carbon dioxid has accumulated and this per- 
centage is again reached. If the percentage of the 
carbon dioxid is increased above 5 per cent, the respira- 
tion becomes more rapid, until the amount agaia 
becomes normal. 

The arterial blood leaves the lungs with the same 
percentage of carbon dioxid in it as is in the alveolar 
air, and this carbon dioxid content of the blood stimu- 
lates or depresses the respiratory center, depending on 
the amount of the carbon dioxid in the blood. There- 
fore, this gas is a regulator of the respiration. Exer- 
cise increases the carbon dioxid, and hence the respira- 
tion is increased. 

The alveolar air contains about 16 per cent, of 
oxygen, and the red blood-corpuscles in the blood of 
the left heart normally contain all they will absorb. 
Crowder^ says that if the oxygen is diminished in the 
lungs to 12 per cent, or less the corpuscles will still 
take up their full quota. He also states that neither 
a surplus nor a deficiency of oxygen in the air supplied 

3. Crowder, T. R.: On the Reinspiration of Expired Air, Arch. Int. 
Med., October, 1913, p. 420. 



CHEMICAL CONSTITUENTS 69 

the lungs, unless the difference is extreme, will cause 
a change in the oxygen content of the red corpuscles. 
Actual need of oxygen will not increase respiration if 
at the same time the carbon dioxid in the alveolar air 
is reduced ; that is, the carbon dioxid must equal 5 per 
cent, for normal respiration to occur. He emphasizes 
the fact that "with each breath we take back into the 
lungs the air contained in the nose and larger bronchi 
— the Mead-space' air. This 'dead-space' air consti- 
tutes about one-third of the whole volume of quiet 
inspiration and not less than one-tenth of deep breath- 
ing. To all intents and purposes it is expired air which 
is constantly reinspired." 

Hence the degree of contamination of the air in a 
room with carbon dioxid does not affect the individual, 
but the amount of water vapor does. It is not rebreath- 
ing the same old air, either of our own breath or 
of others, that mainly affects us, but it is the water 
vapor which prevents the air exchange on the surface 
of our bodies, and especially stagnant, overmoist air, 
that depresses and debilitates us. 

Crowder has fully shown that we rebreathe our own 
inspired air over and over again. Hence it is not pure 
air we breathe. This is true when at rest, true when 
in bed, especially true in some confined sleeping posi- 
tions. It is true with open windows, and in most tents 
and on verandas, and even in actual open air, unless 
the wind blows freely across our faces. In the latter 
case the depth of the breathing is reduced, and we 
might reexchange the air of the upper air passages 
more or less all night even while sleeping with the face 
exposed to the wind. 

None of this militates against the value of clean, 
fresh air as a stimulant to the metabolism, and there- 
fore to health, but it does show that the chemical con- 
stituency of the air is not primarily important, while 
the temperature and moisture are. Dry, cool air is 
bracing; dry warm air, if in motion, may be comfort- 
able and not depressing ; but warm, moist stagnant air 



70 DISSEMINATION OF CONTAGION 

is very depressing to metabolism, and hence when such 
a condition occurs in houses, stores, factories or assem- 
blage halls harm is done to the individual in amount 
depending on the hours he spends in such an atmos- 
phere. Overheating of houses and schoolrooms is 
harmful; too great humidity is also bad, although a 
too dry atmosphere is not desirable. 

DISSEMINATION OF CONTAGION 

The wonderful progress in medicine is in no way 
shown more than by the knowledge acquired by the 
bacteriologists and by the wonderful experimental 
work of the laboratory workers. The various funds 
devoted to this work are paying large dividends in 
preventive medicine. Experimentation with the higher 
animals which more closely resemble human beings has 
disclosed many truths hitherto unknown regarding 
pathology, bacteriology and contagious diseases. 

It was formerly believed that infectious material, 
which was not then known to consist of micro-organ- 
isms, was carried through the air for considerable dis- 
tances. With small-pox it was believed that infection 
could travel several thousand feet. It has now been 
shown that this disease cannot pass through the air 
more than a few feet.* 

Infectious material from patients suffering from dis- 
ease of any kind may adhere to clothing, furniture, 
books and similar articles and may be carried from one 
person to another and be a means of infecting other 
individuals, but this method of transmission is at the 
present time believed to be uncommon. Ordinarily a 
contagious disease is acquired by direct contact and 
largely by the patient breathing in germs or particles 
of infected matter which have been expelled from the 
person affected with the disease by sneezing, coughing, 
or even loud talking. 

4. Kiefer, G. L. : The Control of Contagious Diseases in a Munici- 
pality, The Journal A. M. A., Dec. 7, 1912, p. 2022. 



TUBERCLE— DIPHTHERIA— TYPHOID 71 

A frequent means of transmitting disease from one 
person to another is by so-called "missed cases," that 
is, patients who have the disease in such a mild form 
that it is not recognized. This is especially likely to 
happen with diphtheria and scarlet fever. Another 
frequent source of acquiring disease is by means of 
so-called "carriers," that is, persons who have in their 
throats or other parts of the body the micro-organism 
of a disease, but who do not know they have the dis- 
ease and are not made ill by the germs. 

Some pathogenic bacteria die so quickly after leaving 
the body that infection from dust or air contaminated 
by them is practically impossible. Such are notably the 
germs of influenza, cerebrospinal fever and gonorrhea. 
In these diseases direct contact is the only probable 
method of transmission. This does not detract from 
the fact that not infrequently contagion is conveyed 
to well persons who come in contact with mucus or 
mucopus containing living germs. 

Tubercle, diphtheria and typhoid bacilli, on the other 
hand, may survive drying and be wafted in the dust, 
but infection by means of such dust is probably very 
rare. Droplet contamination of air and of articles 
immediately about a person infected with pulmonary 
tuberculosis or diphtheria frequently occurs. 

The air of sewers has been shown to contain few 
pathogenic organisms, except in very rare instances. 
A few colon bacilli have been found, but then in such 
small numbers that the danger of infection from 
inhaling such gas is practically nil. 

Even if the dust of a room is shown to contain viable 
tubercle or typhoid bacilli, the number of such in the 
upper air of the room would ordinarily be so few that 
infection in this way is practically impossible. Young 
children playing about the floor of such a room, how- 
ever, would be in danger of infection, and infection 
with tuberculosis in children is doubtless frequently 
thus acquired. 



72 INFLUENZA— MEASLES 

Investigation seems to show that the pathogenic 
bowel germs are rarely air-borne, and that the infec- 
tion cannot be thus acquired. Such germs are those 
of typhoid fever, paratyphoid fever, dysentery, diar- 
rhea and cholera. Typhus fever is not air-borne, but is 
due to the bites of the infected body- or head-louse. 
Bubonic plague is transmitted by the bite of an infected 
flea. 

The rapidly spreading influenza (the grip) seemed 
surely to be disseminated by dust or to be air-borne, 
but it seems that, like tonsillitis, diphtheria and ordi- 
nary colds, it is contracted by contact either with the 
infected person or with contaminated substances, as 
clothing, handkerchiefs, furniture, eating and drinking 
utensils, etc. The same is true of eye inflammations 
and contagious skin diseases. This has long been 
known to be true of syphilis and gonorrhea. 

Much more difficult for medical men, to say nothing 
of laymen, to believe is what must now be considered 
a fact, namely, that the scales of desquamating scarlet 
fever are not contagious and do not carry the con- 
tagium; scarlet fever is spread only by contact with 
the infected person or with articles infected by the 
patient having the disease. 

Measles, apparently the most readily spread of any 
contagion, seems to be transferred only by contact. It 
was suspected that this disease was transmitted by the 
air because a child could disseminate it so many days 
before he was actually sick and confined to the house 
or bed. Whooping-cough, "German measles" and 
chicken-pox are all probably spread by contact and not 
by diffusion through the air. Small-pox, as stated 
above, is spread only by contact. 

It has been shown in hospitals that if the nurses 
are careful not to allow contact with other patients, 
small-pox, measles and scarlet fever, the most con- 
tagious of all diseases, may be cared for in adjacent 
wards, and even, in careful experiments, in adjacent 



FLIES n 

beds, without infection of others. Of course, such 
close association of a contagious disease with those 
who have not the disease is absurd on account of the 
failure, in the routine work, of nurses and attendants 
to carry out strict measures to prevent contact or the 
transmission of contaminated articles from one to 
another. Therefore, there should be separate wards, 
if not separate buildings, for the different contagious 
diseases; but the experimentation mentioned above 
shows conclusively that these diseases are spread by 
contact only. 

It is now recognized in hospital operating rooms 
that droplet infection is a danger, if all other sources 
of infecting the wound are excluded, and hence sur- 
geons and their assistants wear mouth and nose covers 
lest they cough, sneeze or speak energetically, and 
thus spray the region of the wound. 

It is hardly probable that pneumonia and acute rheu- 
matism can be spread in any other way than by con- 
tact. It is possible that these more or less constantly 
present germs may require only a certain condition of 
the mouth, upper air passages and system to infect us. 
Cerebrospinal fever and infantile paralysis doubtless 
require contact, and are probably not air-borne. It 
should also ever be remembered, in considering the 
possibility of an air- or dust-borne infection, that it 
requires a large number of most germs to cause an 
infection; a few would ordinarily be killed off before 
infection could occur. 

FLIES 

The ubiquitous fly is a menace and a distinct and 
positive source of danger. He can disseminate typhoid, 
diarrhea and dysenteric germs, and probably also the 
germs of tuberculosis, diphtheria, scarlet fever, cere- 
brospinal meningitis, small-pox, carbuncle, tetanus, 
rabies, anterior poliomyelitis, and even germs from 
granular lids. Also these insects can harbor, for long 



74 MALARIAL FEVERS 

periods, in their bodies the various pathogenic germs. 
Frozen flies from a hospital, after being externally 
cleansed and dried and then powdered and cultured, 
have been shown to harbor staphylococci, streptococci, 
colon bacilli and about fifty other kinds of bacteria. 
Experiments have shown that when a fly is fed on 
such bacteria as the typhoid bacillus and streptococci, 
and later cultures taken from its dead body, these 
cultures will show pure growths of the bacteria on 
which the fly was fed.^ Consequently, not even a dead 
fly is a good one, and all dead flies should be cremated 
if not washed down the sewers. 

House and stable flies are not supposed to stray 
ordinarily more than 500 yards from their breeding- 
places, but winds may carry them farther. It should 
be regarded as an axiom that all breeding-places 
(manure heaps and filth) should be abolished, or 
receive such treatment as to prevent the growth of the 
flies, and in this object there should be cooperation of 
families, tenement owners, towns and cities.^ 

Infected flies may be readily carried on horses or in 
vehicles of all kinds for long distances, and may be 
the source of infection of patients far removed from 
the contagion, and the transportation of germs by flies 
doubtless accounts for many new foci of disease. 

MALARIAL FEVERS 

Thousands of lives are lost in the United States 
from malarial fever, and many thousands of persons 
are incapacitated for days and weeks by such fevers. 

Although the subject of mosquitoes has already been 
touched on, it may be again emphasized that the public 
should know, and children in schools should be taught, 
that the anopheles mosquito, which inhabits swampy 
places and does not ordinarily fly far, and only comes 

5. Berezoflf: Russk. Vracli, June 29, 1913. 

6. For methods of prevention of the growth of flies see Department 
of Agriculture Bulletin 118, issued July 14, 1914, 



ERADICATION OF MALARIA 75 

out of its lair and bites at night, is the only source, as 
far as we know, of what is termed malarial fever. 

This mosquito is innocent of harm until it has sucked 
blood infected with malarial plasmodia, capable of 
development, from a human being. When these germs 
develop into spores and are excreted by the mosquito's 
salivary glands she is able to infect an innocent human 
being. The female mosquito will harbor these germs 
until she dies, unless she is subjected to a temperature 
below 60 F. Hence in regions where the temperature 
falls below this point for a shorter or longer period, 
these infected mosquitoes are no longer able to infect 
human beings. The source, therefore, of the next 
season's infection is in human "carriers" of malarial 
germs, in most parts of our continent, except where it 
is always warm. 

The question, then, is. Can we eradicate malarial 
Plasmodia from human beings ? Probably yes is a cor- 
rect answer if we follow what has been scientifically 
ascertained, namely, that quinin in proper dosage will 
stop acute malarial fever in two or three days. But as 
this quinin destroys only the asexual forms, that is, the 
form that causes paroxysms, while the sexual or repro- 
ductive forms may live and redevelop for infection of 
the mosquito, or to cause a reinfection and symptoms 
in the patient, the drug should be again given for two 
days of each week for a period of eight weeks to be 
sure of complete elimination of the germ ; or it may be 
as well to give the patient a daily dose for eight weeks 
to eradicate the germs and their spores completely and 
to prevent the infection of future mosquitoes. If every 
physician carried out this plan, and every patient 
allowed it, malarial fever would become unusual. 

It may again be mentioned that kerosene or crude 
petroleum sprayed on stagnant water or wet places will 
prevent the development of mosquitoes. One ounce 
of kerosene will cover 15 square feet of water surface. 
Stagnant water should not be allowed. 



76 DISINFECTION 

DISINFECTION OF SCHOOLS 

In view of the fact that contact is apparently a neces- 
sity for the spread of almost all, if not all, of the 
contagions that visit schoolchildren, disinfection, as so 
long practiced, is unnecessary and a delusion. Also 
the closing of schools is unnecessary. Fumigation of 
schoolrooms and schoolbuildings has been abolished in 
many large cities. The ordinary care of the school- 
room involves the free admission of sunlight and pure 
air and the removal of dust by a vacuum cleaner or 
by moist sweeping or mopping. 

If a contagious disease occurs, (a) the child's desk, 
chair, and the immediately surrounding desks and 
chairs, as well as the floor, should be sprayed and 
washed with a strong solution of a germicide or dis- 
infectant, (h) The child's books, pencils, etc., should 
be destroyed, unless the books are valuable, in which 
case they should be subjected to dry heat or to formal- 
dehyd cabinet fumigation, (c) The pupil's clothing 
should be boiled or efficiently fumigated before he 
returns to school. 

There is no question that most all so-called children's 
contagious diseases are more prevalent during the 
months that schools are in session than during vaca- 
tion times. Hence schools do distribute infection by 
allowing crowding and close association with infected 
persons; also because the confinement diminishes the 
resisting power of the well. Therefore, the necessity 
for cleanliness, freedom from dust and for fresh air 
and sunlight is readily recognized. 

DISINFECTION 

Fresh air and sunlight let freely into infected rooms 
and into the sickrooms aid in killing germs and curing 
the patients. Schoolrooms with open windows and 
open-air schools have less contagion than ordinary 
schoolrooms. 



FUMIGATION 11 

Oxygen is not a very active bactericidal agent. Ozone 
if brought to the germ is effective, but pure ozone is 
difficult to furnish to infected rooms or to introduce 
into infected parts of the body, and ozone treatments 
of infection are generally fallacious and fraudulent. 
Hydrogen peroxid solutions, if fresh and uncontami- 
nated, are efficient in killing germs, when brought into 
contact with them. To be efficient the strength should 
be 50 per cent, of aqua hydrogenii dioxidi. 

Fumigation after scarlet fever, diphtheria and 
measles does not seem to pay for the cost and trouble 
it causes, and should be abolished. Proper fumigation 
with strong f ormaldehyd, carried out by boards of 
health, should still be done for small-pox and tubercu- 
losis, and perhaps for erysipelas, childbed fever and 
tetanus, especially in hospitals. Spraying with germi- 
cides of all the immediate surroundings of an infected 
patient is the method of disinfection now most satis- 
factory. All washable clothing and bedclothing should 
be boiled: all other clothing should be baked and put 
into the sunlight. Carpets and rugs should be washed 
with antiseptics. Various washing solutions may be 
used, such as chlorinated lime solutions, 5 per cent., 
formaldehyd solutions, corrosive sublimate solutions 
1 : 500, 5 per cent, phenol (carbolic acid) solutions, or 
better, the higher coal-tar disinfectants, as liquor cre- 
solis compositus. The New York Board of Health 
orders the woodwork and floors scrubbed with hot 
solution of 1 pound of washing soda to 3 gallons of hot 
water. Bedding and night clothing are ordered soaked 
in phenol solutions and then poiled in soapsuds for 
half an hour. Books and toys should be burned. 

Dr. Dixon,'^ Commissioner of Health of Pennsyl- 
vania, suggests as a substitute for the combination of 
potassium permanganate and formaldehyd, the follow- 
ing: "sodium dichromate, 10 ounces avoirdupois; sat- 

7. Dixon, S. G. : A Substitute for Potassium Permanganate to Liber- 
ate Formaldehyd Gas from a Water Solution, The Journal A. M. A., 
Sept. 19, 1914, p. 1025. 



78 PERSONAL HYGIENE 

urated solution of formaldehyd gas, 1 pint; sulphuric 
acid, commercial, 1^^ fluidounces." He states that the 
sulphuric acid and formaldehyd gas form a stable solu- 
tion. "This, after it cools, should be poured over the 
crystals of sodium dichromate spread out in a thin layer 
over the bottom of an earthenware vessel having ten 
times the capacity of the volume of the ingredients 
used." He finds this process more rapid than the com- 
bination with potassium permanganate. 

The danger to others lies in carriers and missed 
cases, those who are so mildly sick as to escape medical 
care. 

The contagious disease hospital is the only safe 
place for tenement cases; this prevents the infection 
of others, as families in tenements have no isolation 
rooms and no trained nurses to carry out disinfection. 

PERSONAL HYGIENE OF SCHOOLCHILDREN 

The schoolteacher and the trained nurse should note 
and correct many things found wrong in a child. They 
should also teach many simple truths as to hygiene. 
Only a few obvious hygienic mistakes will be touched 
on before conditions that may cause infection of others 
are discussed. 

Feet. — A good working rule is for broad-toed shoes 
always ; no heels for the earlier years of the child ; low 
heels later; and if must be, still later, heels a little 
higher. Rubber heels are all right if desired, but not 
rubber soles, unless perhaps for playing tennis. The 
weight of a rubber-soled and heeled shoe is too great 
for constant, or even for a few hours' continuous use. 
Also, completely rubber-soled and heeled shoes cause 
the feet to perspire, to say nothing of the undesired 
insulation of the person. Low shoes for summer, high 
shoes for winter and rainy weather, and storm shoes 
or rubber overshoes for rain and snow are necessities 
for health. If a child wears rubber boots in stormy 
weather, they should be removed while in school. 



HYGIENE OF THE SKIN 79 

Occasional observations of a child's feet and insistence 
that proper shoes be worn will prevent future corns, 
bunions and weakened arches. Too short and too 
narrow-toed shoes ruin the feet of young men and 
young women. Also, this continuous dancing fad 
causes corns and callouses to occur on different parts of 
the toes, which means future trouble, if not properly 
cared for or prevented. 

Hygiene of the Skin. — Briefly to refresh our mem- 
ory as to the anatomy and physiology of the skin, it 
may be noted that the different layers of the cells of 
the epidermis, or horny layer of the skin, change their 
chemical structure as they advance to the outer layer. 
They gradually die, so to speak, and then are cast off. 
This layer contains no blood-vessels and no lymph- 
channels, and is a distinct protection to the body 
against the absorption of toxins and germs. If this 
layer is broken by injury, an absorptive area is imme- 
diately presented, and infection may readily occur. 
Nature makes this protective layer thickest where 
injury is likely to be the greatest, such as the palms of 
the hands and the soles of the feet. The hair and 
nails are really projections of this layer of horny cells. 

Some drugs in solution or ointment may be rubbed 
or massaged through the horny layer into the layers 
of absorption, that is, the rete layer. Irritants may 
also reach this layer after more or less corrosion or 
removal of the epidermal layer, and local inflammation 
may be caused. It is the rete layer that is especially 
inflamed in many conditions of eczema. 

The sebaceous glands of the skin may be overactive 
or underactive. If they are overactive, too much oily 
substance reaches the skin and hair and the parts 
become greasy. If the opening of a gland becomes 
clogged with dust or other particles, the canal and 
gland become more or less congested and the result is 
a so-called comedo or blackhead, and pathogenic 
germs may grow, especially the pus-forming germs, and 



80 PERSPIRATION 

a condition of acne or infection occur. If these seba- 
ceous glands secrete insufficiently, the skin becomes 
dry and scaly, perhaps brittle, cracks readily, insensible 
perspiration is interfered with, and the whole system 
may be more or less affected, depending on the serious- 
ness of this condition. 

The sweat-glands must be sufficiently active for the 
body to be in perfect health; they largely eliminate 
water, reduce the temperature of the body and keep 
the internal temperature normal. The few salts and 
the small traces of nitrogen that are eliminated by the 
sweat-glands may be disregarded ; suffice it to say that 
the excretion of poisonous nitrogen compounds by the 
sweat-glands is very small. The odor of the perspira- 
tion varies with different individuals and with differ- 
ent races. Not infrequently it is intensely disagree- 
able, and the secretion, both as to odor and character 
and the amount of decomposition of fatty acids, varies 
with the part of the body from which the perspiration 
comes. When the sweat from an individual gives off 
a very disagreeable odor, the condition is termed 
bromidrosis, and requires treatment by a physician. 
The condition should be noted in children, and pre- 
vented if possible. 

Dandruff and dirty, greasy scalps and insufficient 
cleanliness of the hair should be noted, and instruc- 
tions given as to the proper care of the child's head. 
A good daily brushing, and a simple castile soap sham- 
poo weekly (or at least once in two weeks), with 
proper drying of the scalp, should be given by the 
mother. 

Besides the advice given the parents as to the care 
of the child's scalp, the teacher or nurse should note 
the condition of the child's skin as to cleanliness, 
greasiness, dryness or eruptions, and proper advice 
should be transmitted to the parents. Also, the con- 
dition of the clothing and the kind of underclothing 



CONTAGIOUS SKIN DISEASES 81 

should be noted, especially in young children, and if 
considered improper, similar advice should be given the 
parents on the subject of underclothing. 

Children and parents should be instructed not to use 
strong, irritant soaps, and parents should be urged to 
seek medical advice when a child's skin is too greasy 
and acne of the face is beginning to develop, when 
the child's skin is too dry for health, and when there is 
any eruption. They should be warned against the use 
of all nostrums, whether ointments or liquids, as liable 
to cause more harm than good. Parents should be 
advised to give their children only the simplest kind of 
food, to give them no tea and coffee, and to forbid 
their eating large amounts of sweets ; especially is such 
advice necessary when there are eruptions on the skin. 

Contagious Skin Diseases — The principal con- 
tagiums that occur on the skin of schoolchildren are 
ringworm, body- and head-lice and scabies. None of 
these conditions can be well treated at the school or in 
dispensaries, but the treatment must be carried out at 
the home of the infected child. No verbal or written 
instructions will accomplish half so much as a visit 
from the trained nurse and her personal instruction 
of the parents. Also she can take a general survey of 
the other children of the family and of the household. 

It is not necessary to describe the treatment for 
these several troublesome but simple conditions. The 
various parasiticides are well understood, but the 
whole success of treatment lies in the care exercised 
and the curative measures taken in the child's home. 
When the patient's family can afford it, the Roentgen- 
ray treatment of ringworm is perhaps the ideal treat- 
ment. 

Body-lice rarely occur in children and demand a 
cleansing bath and the baking of the underclothing in 
an oven at a temperature above the boiling point, but 
not high enough to burn the clothing. 



82 PEDICULOSIS 

Pediculosis Capitis. — Aside from being an evidence 
of neglect, the head-louse may be the means of con- 
veying infection, for example, of typhus fever. 

Dr. Jacob SobeP of the Department of Health of 
New York City describes the method of handling this 
infection in New York, and also shows how greatly 
the disease has been reduced by the home instructions 
that the board of health has inaugurated. Following 
are the instructions issued by the New York board of 
health to the parents of children who are found to be 
infected with pediculi: 

Children affected with vermin of the head are excluded 
from school. The following directions will cure the 
condition : 

Mix ^2 pint of sweet oil and ^^ pint of kerosene oil. Shake 
the mixture well and saturate the hair with the mixture. 
Then wrap the head in a large bath-towel or rubber cap so 
that the head is entirely covered; the head must remain 
covered from six to eight hours. 

(Tincture of larkspur may be used instead of oil mixture. 
The directions for use are the same.) 

After removing the towel, the head should be shampooed 
as follows : 

To 2 quarts of warm water add 1 teaspoonful of sodium 
carbonate. Wet the hair with this solution and then apply 
castile soap and rub the head thoroughly about ten minutes. 
Wash the soap out of the hair with repeated washing of clear 
warm water. Dry the hair thoroughly. 

Nits : If the head is shampooed regularly each week as 
above described, it will cure and prevent the condition of 
"nits." 

Vulvovaginitis. — Just what methods are advisable to 
determine that a female child has vulvovaginitis, which 
may be transmitted to others by the school water- 
closets and by other means of transmission, is difficult 
to outline. It must be recognized, however, that a 
great deal of this condition occurs in young girls. The 
discharge may be non-specific, or may be associated 
with some eruption or irritation of the genital region, 

8. Sobel, Jacob: New York Med. Jour., Oct. 4, 1913, p. 656. 



VULVOVAGINITIS 83 

or it may be actually due to an infection from gono- 
cocci. Microscopic examination and bacteriologic cul- 
tures are the only means of determining the character 
of the discharge. 

It being ascertained that a girl has a discharge, it 
is the duty of the medical inspector or trained nurse 
to insist that the family have their physician properly 
treat the patient. The necessity of bacteriologic exam- 
ination must be emphasized, the danger of contagion 
urged, and the necessity for ascertaining the source 
of the child's infection discovered, if possible. 

It is certain that these little patients frequently mas- 
turbate; whether this is a cause of the inflammation, 
or whether the irritation causes the bad habit, is a 
matter of unimportance. Feeble-minded girls are 
likely to have a vaginal discharge, and have been found 
to be often infected with gonorrhea. 

Dr. F. G. Taussig® urges the following measures to 
prevent the vaginal infection from entering institu- 
tions such as orphan asylums and children's homes : 

First, he would examine a vaginal smear from all 
girls applying for admission, and if gonorrheal infec- 
tion is discovered, the child should be excluded until 
cured. If the disease is discovered in an institution, 
the patient should be isolated and the nurse in atten- 
dance should take measures to prevent the infection 
of others. 

As further preventive measures of gonorrheal infec- 
tion of female children, Taussig advises that 1 drop of 
a 2 per cent, silver nitrate solution be instilled into 
the vestibule of the vagina at the birth of every female 
child whose mother shows evidence of gonorrhea. He 
would advise this even if only about 5 per cent, of 
gonorrheal vaginitis in young children occurs directly 
after birth. He also believes that "the adoption of 
the U-shaped seat with low bowl and other precau- 
tionary measures to prevent the spread of the infection 

9. Taussig, F. G.: Am. Jour. Med. Sc, October, 1914, p. 480. 



84 TEETH AND MOUTH 

in the lavatories in schools, playgrounds, comfort sta- 
tions and tenements" would prevent a great many 
cases of innocent infection. 

The curative treatment is the gentle, frequent cleans- 
ing douche, as warm boric acid or borax solutions, 
and the more or less frequent applications of silver salt 
solutions. The little patient should not be considered 
cured until several examinations of the smear have 
shown gonococci to be absent. 

CARE OF THE TEETH AND MOUTH 

The importance of oral cleanliness is becoming more 
widely recognized. The discovery that individuals, 
apparently well, may be carriers of pathogenic germs, 
especially of the bacillus of diphtheria, of the pneu- 
mococcus and of the bacillus of influenza, makes per- 
sons so infected a menace to their associates. How 
frequently the pneumococcus causes pneumonia in one 
who carries this germ accidentally is of course not 
known. Whether an individual who develops pneu- 
monia always receives an acute infection with this 
germ, or whether, becoming debilitated by an influ- 
enza or a cold caused by some other germs, he has his 
resisting power so reduced that the pneumococci pres- 
ent in his mouth and throat cause active infection, 
cannot readily be determined. Streptococci and staph- 
ylococci are of frequent occurrence in the mouth, espe- 
cially when there are decayed teeth, or diseased gums, 
tonsils, noses or any of the sinuses surrounding these 
regions. Whether these germs so present in a person's 
mouth frequently or infrequently infect others need 
not be considered. It is certain that the carriers of the 
germs are a constant source of danger to themselves, 
not only on account of the local disturbance, which 
may become more or less permanent with more or less 
disorganization or disintegration of solid tissues, but 
also from the danger of septic and pyemic infection. 
From such local infections joint inflammations are fre- 



TOOTH BRUSH 85 

quently caused, whether or not this is the case with 
true rheumatism, endocardial inflammations, and pos- 
sibly such serious blood disturbances as pernicious 
anemia or leukemia. More or less serious glandular 
disturbances may occur from these local putridities or 
suppurations and the lungs are in constant danger 
from infection from these organisms. Some of these 
bacteria may also cause conditions that allow an infec- 
tion by tubercle bacilli. Chronic nephritis must also 
be listed as an occasional consequence of a local infec- 
tion in the mouth, nose or throat. 

More or less constantly these pathogenic germs must 
be swallowed with food, drink and saliva. Probably 
most of them are killed by the hydrochloric acid of the 
gastric juice, provided the stomach is normal. If the 
stomach secretions are imperfect or if there is a 
chronic congestion of the mucous membrane of the 
stomach, many of these germs doubtless pass alive into 
the intestine and may there be a cause of a chronic 
enteritis or an infection of the gall-bladder, or they 
may possibly disturb the pancreas, and may be the 
cause of an ultimate incurable organic disease or 
incurable blood disturbance. 

The corollary of the foregoing, and the possible and 
more or less frequent results of mouth infection which 
have not been overestimated, is cleanliness of the 
mouth, nose and throat. The teeth and mouth should 
at least be thoroughly cleansed on rising in the morn- 
ing and on going to bed at night. A thorough use of 
the tooth-brush with such tooth-powders or tooth- 
pastes as seem advisable, depending on the age of the 
person and the condition of the gums and the character 
of the deposits that occur on the teeth, should be made 
daily. Some teeth cleanse readily and do not require 
a very stiff brush or very harsh treatment. Others 
need a stiffer brush and a powder, not too soapy, for 
complete removal of all deposits. If the gums bleed 
readily, they should be hardened with simple astringent 



86 NOSTRILS AND THROAT 

washes, either a dilute alcohol or a dilute astringent 
tincture such as myrrh, or a tannic acid wash. Potas- 
sium chlorate mouth-washes and gargles are very 
soothing to irritated mucous membranes, but ordinarily 
any simple alkaline wash or mildly antiseptic solution 
as borax or boric acid solutions will be found sufficient, 
with the proper rubbing of the gums with a not too 
hard tooth-brush, or rubbing the gums with the fingers, 
that is, massage. The powder selected for cleansing 
the teeth is generally alkaline, with chalk or magnesia, 
but it has been shown that acid cleansing preparations, 
especially the acid fruits, are more efficient in causing 
the death of bacteria that occur in the mouth.^" What- 
ever powder is chosen, it should contain no hard crys- 
tals that could possibly injure the enamel of the teeth. 
A few children have never been taught to cleanse 
their teeth at all; many children have never been 
taught the proper manner of cleansing their teeth. 
Consequently, it should be the duty of the trained 
nurses of schools not only to examine the condition of 
the teeth and mouth of the children, but also to instruct 
them how to use their tooth-brushes, and what the 
hygiene of the mouth means. Some physicians urge 
that there should be daily gargling with some simple 
mouth-wash or physiologic saline solution, and also 
urge the snuffing into the nostrils and then expelling 
of such solutions. Theoretically, cleansing of the 
nostrils from the dust and bacteria inhaled should be 
a daily dut}^ Washing the mouth and throat with 
some simple solution should also be daily done. Prac- 
tically, however, it is difficult to enforce such advice. 
Also, as far as the nostrils are concerned, solutions 
and sprays may irritate the mucous membrane, or may 
remove Nature's protective mucus. For this reason 
it may not be advisable generally to recommend wash- 

10. Oral Cleanliness, Therapeutics, The Journal A. M. A., Nov. 8, 
1913, p. 1719. 



PYORRHEA 87 

ing of the deeper parts of the nostrils with antiseptic 
or other solutions. 

The removal of hopelessly decayed teeth and the 
filling of the cavities in teeth that can be preserved are 
essential to health. The trained nurse should discover 
such teeth in children and strongly advise, if not insist, 
that they be properly attended to. Alveolar abscesses, 
or other localized infection, should be treated by the 
physician or dentist until cured. Temporary frequent 
washing of all pus parts, unless the cavity is more or 
less closed, with hydrogen peroxid solutions, the dilu- 
tion depending on the part affected, is efficient until the 
diseased part can be more thoroughly treated. 

Pyorrhea alveolaris, very frequent in adults, very 
rare in children (unless the child is generally debili- 
tated, or in children who have rickets) is a germ dis- 
ease that is cured only by the most persistent and con- 
tinuous treatment. Cleanliness and antiseptic wash- 
ings are the means of prevention, but these rarely will 
cause a cure. lodin treatment by the dentist will some- 
times cure up pockets of infection. In inveterate cases 
vaccines, especially autogenous vaccines, have many 
times proved efficient. Sinus diseases are well treated 
only by nose and throat specialists. 

Let it be urged that it is a mistake to retain too long 
a tooth that is causing disturbance. Many a serious 
condition and a great deal of jaw, and even antrum 
trouble has been caused by trying to preserve a tooth 
that is diseased at its root, or has a pocket of infection 
running down from the gum toward the root. A tooth 
that is diseased and cannot be well treated from the 
surface and which tends to cause serious disturbance 
of the fifth nerve, and especially if the pain comes in 
spasms, cannot be too soon removed. Dentists are 
often too conservative. Roentgenograms of the con- 
ditions in a jaw will often show a diseased tooth, or 
ill-placed teeth, which may be the cause of pain. 



88 ADENOIDS 

A few more suggestions might not be out of place. 

First, the tooth-brush should not only be a good one, 
and not have loose bristles to cause injury or to be 
retained in the mouth or throat, but the brush should 
be deposited in an antiseptic solution. Of what value 
is it to cleanse the germs from the mouth and teeth 
and then allow them to grow in the tooth-brush to 
become a source of infection for following days? 
After using, the tooth-brush should be cleansed and 
placed in a test-tube or a bottle holder with alcohol or 
in a weak formaldehyd solution, as 1 part of liquor 
formaldehydi to 25 parts of water. 

Second, the constant and frequent use of hydrogen 
peroxid solutions, which has become more or less of a 
fad with many persons, is a mistake. It is not good 
for the teeth, and not good for the gums, although it 
is used and should be used in septic or infected con- 
ditions,, but not then for too long. 

Third, the teeth and mouth should receive a great 
deal of care and attention during all illness, whatever 
that illness may be. 

Fourth, before all operations which are not of the 
emergency type, the teeth and gums should be put into 
good condition by the patient's dentist. Before opera- 
tion in all cases the m^outh, teeth and gums should be 
thoroughly cleansed and cleaned with hydrogen per- 
oxid or other antiseptic solution. 

adenoids; hypertrophied tonsils; otorrhea; cer- 
vical ADENITIS 

While any one or any two of these conditions may 
occur w^ithout the others, they are all more or less 
closely associated, and the schoolteacher and the 
trained nurse should take note if any one of them is 
present in a child, and the child should then be sent to 
the medical inspector or medical examiner. The 
importance of treating hypertrophied and diseased 
tonsils has already been discussed. The association of 



OTORRHEA 89 

mouth and throat diseases with cervical adenitis is well 
understood. Also the necessity for removing obstruc- 
tive adenoids which hinder proper breathing and pre- 
vent the removal of dust particles and germs and the 
warming of the air, requires no discussion. 

Adenoids not only cause and allow nasal catarrh, 
recurrent tonsillitis, chronic pharyngitis, and even 
bronchitis with perhaps, later, the development of cer- 
vical adenitis, but they may also be a cause of obstruc- 
tion of the eustachian tubes and disturbance and infec- 
tion of the ears. They may allow infection of the 
sinuses associated with the nostrils, and they may pre- 
vent the proper development of the bones of the face, 
the proper growth of the nose and cause that vacant, 
open-mouth expression, which is so perfectly charac- 
teristic of this simple but frequent condition. It is 
needless to urge that the earlier obstructive or hyper- 
trophied adenoids are removed, the less likely are com- 
plications to occur and the more normal will be the 
growth of the bones of the face, nose and jaw. 

The seriousness of discharging ears will be recog- 
nized when Dr. N. P. Stauffer's statements'^ are 
repeated, that, of 90,000 deaf persons in the United 
States according to the census of 1900, 51,000 were 
deaf from childhood, that 75 per cent, of deafness is 
caused by discharging ears, and that 75 per cent, of 
discharging ears is due to adenoids and hypertrophied 
tonsils. 

With acute adenitis the child has a high temperature, 
and it is soon recognized that he is sick. It should be 
remembered that a child may have folliculitis in the 
nasopharynx which may give infection to others much 
the same as follicular tonsillitis. With chronic enlarge- 
ment of the cervical glands the little patient's temper- 
ature and nutrition should be carefully studied. Also 
any focus of infection in the throat should be noted. 

11. Stauffer, N. P.: New York Med. Jour., Oct. 10, 1914, p. 70S. 



90 ADENITIS 

The best management for the individual patient with 
an enlarged gland or glands is for the decision of the 
family physician. Not all enlarged cervical glands are 
tuberculous ; not all enlarged glands should be removed. 
A suppurating gland, however, should never be neg- 
lected. Also, chronically enlarged cervical glands may 
become infected with tuberculosis, or may be the begin- 
ning of more serious glandular trouble, as Hodgkin's 
disease. In other words, enlarged glands should always 
be looked on with suspicion, and generally the parents 
should be advised that the child should not remain in 
school, but may perhaps attend an open-air or open- 
window school. The treatment should be decided by 
the family physician. It should be noted, however, 
that iodid surely, and arsenic perhaps, will stimulate a 
tuberculous process to more widespread activity. 
Whatever is done, it should be emphasized that a child 
with enlarged glands of the neck is under suspicion of 
ill health as long as such glands are in evidence. 



CHAPTER IV 



THE COMMON INFECTIOUS DISEASES 



PREFACE 

Before taking up these diseases separately, it may 
be well to quote Vaughan's Harvey Lecture^ as to 
what is scientifically understood by a germ pathogenic 
to man, and just what infection means. Briefly, 
Vaughan says that it is the protein poison produced by 
the germ that causes symptoms. If the germ does not 
find in our bodies an albumin suitable for its food, it 
dies and is not pathogenic to us. Also, if our tissues, 
in individual cases, can produce antibodies or opposing 
serums or antitoxins rapidly enough to overcome a 
germ which does find suitable food albumins in us, 
it will die before it intoxicates us, and we become, at 
this time at least, immune. Vaughan also says that 
acute disease or intoxication results when there is 
rapid multiplication of the infecting germs that find 
suitable pabulum, its protein toxins causing rapid 
sensitization of our systems, and a resulting fever 
which is of benefit. If the production of these patho- 
genic germs is slow, the result is a chronic infection, 
and when the proper albumin for the food of these 
germs is formed only in restricted areas, the result is 
a local infection. 



1. Vaughan, Victor C: The Phenomena of Infection, The Journal 
A. M. A., Feb. 21, 1914, p. 583. 



92 DISEASES OF RESPIR.\TORY TRACT 

DISEASE OF THE RESPIRATORY 
TRACT 

Next to disturbances of nutrition in infants and 
young children, colds, inflammations of the air pas- 
sages, are the greatest menace to health. Colds far 
surpass in frequency any other disease condition. 
Generally, the older the child, the less frequent the 
colds, but the susceptibility to catching cold, or the 
cold habit is of very frequent occurrence in individual 
children, in some youths, and even in adults. There is 
no immunity acquired by surviving a coryza, a phar- 
yngitis or a bronchitis ; in fact, ordinarily, the person 
is at least temporarily more susceptible to taking or 
developing a fresh cold. This may not be quite true 
of an influenza or grip cold, because many persons 
have a real or pseudogrip attack early in the fall or 
winter and are then more or less immune from acute 
attacks during the rest of that season ; but there seems 
to be no doubt that the influenza bacillus leaves a 
patient temporarily, at least, more susceptible to other 
more dangerous germs, as the pneumococcus or tuber- 
cle bacillus. Consequently, besides the immediate 
debility that an acute cold causes, the possibility of 
opening the way for the entrance of more serious dis- 
ease should cause every cold to be considered seriously 
and treated energetically. Also, it should be the object 
of every mother, nurse, family physician, schoolteacher, 
medical inspector, board of education and board of 
health to inaugurate every means possible to prevent 
colds, that is, to develop the resisting power of the 
individual ; to see that the child is properly clothed ; to 
see that the house and schoolroom air is as free as 
possible from dust and germs, and that it contains the 
proper amount of moisture, and to take measures to 
prevent individual contagion and widespread irritation 
of the upper air passages from irritants in the air of 
buildings and localities. 

While it is asserted by some that acute colds are 
always due to germs of some kind, it is conceivable that 



PREVENTION OF COLDS 93 

a too dry atmosphere, which is the condition in so 
many houses to-day, may so irritate or congest the nos- 
trils as to allow the least irritant to cause at first a 
simple inflammation of the mucous membrane, which 
congested area may later pick up and harbor, or cease 
to kill, germs. It seems to be an established fact that 
good outdoor air does not predispose to colds as much 
as indoor air, and it is a fact that persons whose occu- 
pation is indoors are more liable to have colds than 
those whose occupation is outdoors. Whether or not 
every cold is due to contagium or to a germ, chilling, 
whether indoors or outdoors, certainly predisposes to 
colds. It is quite probable that chilling of the surface 
of the body congests the inner organs and possibly the 
mucous membranes of the air passages. If the mucous 
membrane of the nose is congested, it more readily 
becomes inflamed by irritation or by germs. 

To repeat, every cold, especially in a young child, 
should be considered serious. The possibility and the 
frequent occurrence of complications such as middle 
ear inflammation, inflammation in one of the accessory 
sinuses of the nose, broncho-pneumonia or lobar pneu- 
monia must always be a subject for consideration and 
prevention if possible. Colds and throat infections are 
also likely to cause enlarged cervical glands and per- 
haps enlarged bronchial glands. Any one or more of 
these glands may become infected with tuberculosis. 
Again, most colds, if not all, are contagious, and are 
transmitted by contact through families or close asso- 
ciates, and are especially spread by contact in schools. 

The first step in the prevention of colds is to ascer- 
tain if the child properly breathes through its nostrils. 
Adenoids and greatly enlarged tonsils should be opera- 
tively treated. Hypertrophied mucous membrane or 
deformed nostrils should be surgically treated, if 
deemed advisable. The nutrition of the child must be 
good ; if a child is underfed, he must receive more food. 
If a child is anemic, he must be properly treated with 
fresh air, good food and iron. Any chronic disease 



94 ACUTE CORYZA 

must be discovered. Swabs should be taken from the 
nose and throat, and cultures made to ascertain if the 
child is harboring a recognizable pathogenic germ. 

ACUTE CORYZA 

This acute nasal catarrh, often called a "cold in the 
head," is of frequent occurrence in some regions, espe- 
cially near the seacoast, and occurs repeatedly in cer- 
tain persons who seem to have a susceptibility to 
inflammation in the nose. Some persons cannot be 
exposed to a single draft on any part of the body 
without an acute coryza starting. Whether their 
mucous membranes are in such a condition as to allow 
a recurrence of inflammation from dust irritants or 
from the congestion caused by chilling, or whether they 
more or less constantly harbor germs which cause 
another acute infection, if the mucous membrane is 
again congested, is a question that has not yet been 
positively determined. It is supposable, however, that 
while most acute nasal catarrhs are due to infectious 
germs, more or less chronically hypertrophied mucous 
membrane and more or less sluggish circulation in this 
membrane may allow simple non- infectious catarrhs to 
occur when irritation of any kind is applied. Other 
persons who do not have this susceptibility may 
become chilled, may be subjected to violent cold, damp 
winds, and may even get wet and still never develop 
a nasal catarrh. Just as large tonsils more readily 
catch germs and become diseased, or more readily har- 
bor germs and have recurrent inflammations, so hyper- 
trophied mucous membrane of the nostrils becomes 
susceptible to reinfection or to reirritation. Frequent 
acute colds, more or less constant subacute inflamma- 
tions, or chronic catarrh may result from such a con- 
dition. 

Some persons are susceptible to certain kinds of irri- 
tants, whether it be a particular kind of dust, a par- 
ticular kind of pollen from plants, or the emanations 
or odors from stables, horses, etc. If this susceptibility 



PATHOLOGY OF CORYZA 95 

is in excess, or occurs at certain times of the year, the 
patient becomes a so-called hay-fever or rose-fever 
sufferer, and then shows symptoms of anaphylaxis. 

The pathology of any acute mucous membrane 
inflammation is divisible into stages, the first being that 
of congestion and dryness of the surface. With this 
congestion there is swelling due to dilatation of the 
blood-vessels and more or less erection of the tissue, 
and with this swelling, if the mucous membrane is in a 
narrow canal, there is more or less obstruction, with 
discomfort, or even pain. 

The next stage of the mucous membrane inflamma- 
tion is the outpouring of a more than normal amount 
of mucus. The surface of the membrane then becomes 
moist, and the pain or discomfort becomes less as the 
tissues become less congested, owing to more or less 
extravasation of watery secretion and white blood- 
corpuscles which sooner or later may become pus. This 
extra secretion is propelled by gravity or by cilia or 
by voluntary expulsive methods to some external ori- 
fice, and the patulency of the part gradually returns. 
If this inflammation persists the secretion becomes 
more and more purulent. With a good outlet, and 
where the irritating and purulent secretions are not too 
long retained, the tendency of the mucous membrane 
is to recover, the pus gradually disappears, the secre- 
tion becomes mucopurulent, then mucus but in an 
abnormal amount, and finally the mucous membrane 
becomes normal, with its normal amount of mucous 
secretion. However, for some time this membrane is 
more susceptible to recurrences of inflammation. 

The mucous membrane of the nose and throat in 
some persons may become abnormally dry. This con- 
dition is more diflicult to treat, and even prolonged 
treatment may not cause it to become normal. Such 
persons have what is termed dry catarrh, and unless 
great care is taken, retain dry strings or plaques of 
secretion that putrefy and cause a disgusting odor to 
the breath, a condition termed ozena. 



96 TREATMENT OF CORYZA 

With a localized acute inflammation of the mucous 
membrane there may or may not be fever, depending on 
the susceptibility of the individual to an irritation, 
some persons developing fever readily, others having 
no fever except under serious provocation. 

Applying this pathology to an acute coryza, it is 
readily understood, with a damming up of the passages 
from congestion and secretion, that germs, both by 
their own movements and by pressure, may migrate or 
be forced into some of the sinuses surrounding the 
nostrils, and the frontal sinuses are those that most 
frequently suffer. This is the cause of the frontal 
headache from the congestion which occurs with most 
colds, and of an actual frontal sinusitis when infection 
actually enters these regions. If the same inflamma- 
tion occurs in the nasopharynx, the mouths of the 
eustachian tubes may become blocked, and middle ear 
congestion from aspiration of the air is caused. Also 
the germs of infection may migrate up these tubes and 
middle ear inflammation develop. 

Treatment 

The preventive measures have already been referred 
to and described. They consist of proper bathing to 
keep the skin in good condition; proper clothing, 
depending on the region, season and exposure ; proper 
heating and ventilation of living rooms, bedrooms and 
buildings in which persons are employed, and in the 
case of the child, proper heating and ventilation of the 
schoolrooms. As previously stated, a child may be 
overclothed for play, as well as underclothed for sitting 
in cool rooms. The child should be extra well clothed, 
if he attends an open-air or open-window school during 
the cold seasons; such schools probably are among 
the greatest means of prevention of cor3^za, sore throats 
and coughs. On the other hand, the too severe expos- 
ure of young children and babies to dampness and 
winds is inexcusable and does not increase their resis- 
tance against catching cold, and often precipitates more 



TREATMENT OF CORYZA 97 

serious conditions. Any person who has a tendency to 
nasal or pharyngeal colds should not suffer undue 
exposure at night. Too many windows being open 
may cause too much direct draft over the face. Fresh- 
air sleeping should be governed by common sense. Cold 
daily sponging of the child's face, neck and chest, fol- 
lowed by quick friction, is a splendid means of decreas- 
ing the likelihood of catching cold or becoming chilled. 
Older persons may take cold showers or cold plunges 
in the morning, if it is advisable in individual cases. 

To repeat, it is urged that while most acute colds, if 
not all, are probably due to germs, still acute conges- 
tion and more or less nasal secretion may be caused by 
drafts or currents of cold air causing chilling of some 
uncovered surface of the body, especially if the person 
is overheated or is perspiring from exertion or from 
being in an overheated room. This congestion forms 
a splendid culture ground for the development of 
germs. 

Children especially should not be subjected to 
unnecessary infection by being taken into crowded 
cars, stores or into various assemblages, where it is 
impracticable to avoid close contact with coughing or 
sneezing persons who do not properly protect the sur- 
rounding atmosphere by using handkerchiefs. 

Schoolchildren with acute colds should either be sent 
home or should be taught to prevent spraying the 
atmosphere with droplets of infection and thus infect- 
ing surrounding children. If a case of acute coryza 
occurs in a family, the family should understand that 
it is contagious, and the sick should be isolated from 
the well as effectively as practicable. 

As so many times urged, a child or adult who has 
repeated colds should be examined and properly treated 
medically or surgically by a nose and throat specialist. 
The family should also be taught that the exchange of 
handkerchiefs and the use of the same towels when one 
member of the family has a cold or sore throat is inex- 
cusable. Direct contagion by this method is probably 



98 ABORTING A COLD 

very frequent. During all colds the nasal and throat 
secretions or excretions should be received into paper 
handkerchiefs, or pieces of cheese-cloth, and either 
immediately burned or deposited in a paper bag for 
burning later. If handkerchiefs are used, they should 
be washed separately and soon. 

The harm which a too dry indoor atmosphere can do 
to mucous membranes of the upper air passages is well 
described by Wolff Freudenthal.^ The drying of these 
mucous membranes caused by evaporation due to the 
inhaling of too dry air leaves the membranes unpro- 
tected, and the first irritant that attacks them may cause 
an inflammation. It is necessary, therefore, to teach 
and advise that more moisture be furnished the air of 
all houses, buildings, schoolrooms, churches, theaters 
and other places of assemblage. 

By all of these methods the frequency and number 
of nasal colds will be greatly diminished. 

Acute coryza having begun, an attempt should be 
made to abort it. There are various methods of reliev- 
ing internal congestions, and the general principles are 
the same in all cases, wherever the localized inflamma- 
tion may be. These general methods are some means 
to reduce an increased temperature, some means of 
bringing the blood to the surface of the body and 
increase perspiration, some means to produce free 
catharsis and thus to deplete the blood-vessels and 
lower the blood-pressure to relieve indirectly the ten- 
sion in the region of congestion, and some means to 
prevent the development of the second stage, or stage 
of secretion, if possible. Methods used to meet one 
of these indications will many times meet one or more 
of the others ; hence the treatment is often very simple. 

If the patient is first seen in the morning, or before 
the middle of the afternoon, the best treatment is a 
saline purge of some description, as exemplified by the 
Seidlitz powder or by the effervescing magnesium cit- 
rate or Rochelle salt, or castor oil if that is preferred. 

1. Freudenthal, Wolff: New York Med. Jour., Jan. 3, 1914, p. 1. 



TREATMENT OF COLDS 99 

If the patient is seen first in the evening, a less quickly 
acting cathartic is advisable, and none is better than a 
small dose of calomel, as from 0.05 to 0.20 gm. (about 
1 to 3 grains), depending on the age of the individual, 
combined with 0.50 to 1 gm. (7^ to 15 grains) of 
sodium bicarbonate. Or, 1 grain of calomel may be 
given with an ordinary compound aloin pill or tablet. 
The old-fashioned Dover's powder is still given by 
many physicians and often works well, but may cause 
considerable nausea. Also, opium or morphin in any 
form tends to inhibit free action of the bowels, which 
is undesirable. One of the best treatments is one of the 
coal-tar products, such as antipyrin, acetanilid or acet- 
phenetidinum. Any one of these may be given in one 
fair-sized dose or in two medium-sized doses, or in 
several small doses. One gm. of antipyrin would be a 
full dose ; 0.50 gm., repeated in five or six hours, would 
be a medium dose ; 0.30 gm. of acetanilid would be a 
large dose, and 0.10 gm. might be repeated at three- 
hour intervals for three times. A satisfactory method 
is a combination of acetanilid with sodium bicarbonate, 
and a prescription similar to the following is often 
very valuable : 

Gm. 

I^ Acetanilldi 0125 or gr. v 

Sodii bicarbonatis 2|50 gr. xl 

M. et fac chartulas 5. 

Sig. : One powder every two or three hours. 

A similar combination may be given in tablets, if pre- 
ferred. It should be remembered that caffein has been 
shown not to protect the heart from depression caused 
by large doses of a coal-tar product; therefore, there 
is no object in adding caffein to such a prescription. 
When these coal-tar products are ordered, it is well 
to give coincidently hot lemonade. Perspiration is more 
readily caused by this means. 

Provided the patient is not soon to be subjected to 
exposure, a hot bath is another efficient means of 
relieving internal congestions, and can be used coinci- 
dently with the other treatment. Acidum acetylsali- 



100 USE OF ACONITE 

cylicum (aspirin) is now more largely used than almost 
any other drug to abort colds. The laity, on account 
of the instruction which they have received of the 
dangers of acetanilid and similar drugs, now all buy 
and use this drug with the greatest freedom. It can 
cause cardiac depression, and should not be used ad 
libitum. If preferred, it may certainly be ordered. 

Rhinitis tablets are sold everywhere to the laity, and 
are largely used by physicians. These are various com- 
binations of morphin, atropin, strychnin and aconitin. 
The minute dose of aconitin ordered probably generally 
has no action. If one desires the activity of aconite, 
it is best to give it in a tangible form and dosage, 
namely, the tincture of aconite, a drop perhaps every 
half hour or hour, until the pulse shows the activity 
of the drug. However, this treatment ordinarily 
requires that the patient be seen within a certain num- 
ber of hours by the physician, to ascertain whether or 
not the aconite should be stopped, unless the doses are 
limited in number. The old aconite treatment of colds 
has mostly given place to the newer treatments 
described above. The whole rhinitis tablet com^bina- 
tion probably represents principally the action of 
atropin with some help from the morphin, both of 
which will dry up the secretions of the nostrils and 
throat. The small amount of strychnin probably is 
not very active. Sometimes minute doses of quinin 
enter into these combinations, but that probably is not 
active. In other words, it is a question if a small dose 
of atropin sulphate, given frequently, does not act as 
well as one of these rhinitis combinations. 

There is no question about the drying up of secre- 
tions by morphin, if this drug is pushed. Rarely is 
such treatment needed. The old-fashioned treatment 
of a hot foot-bath, a hot whisky punch, and the patient 
put to bed is a treatment that is often successful. The 
upper air passages and the head are relieved from con- 
gestion by such treatment, the blood-vessels of the 
surface are dilated by the alcohol, and the patient per- 



TREATMENT OF COLDS 101 

spires more or less and the treatment is conducive to 
comfort. In this age, however, when other vasodi- 
lators are accessible, it is rarely necessary to resort to 
alcohol. 

Quinin sulphate has been used for years as an abor- 
tive treatment of colds, and the laity, until more 
recently adopting acetylsalicylic acid, have always 
resorted to this drug. Small doses would probably 
not have any very decided action; large doses are 
inadvisable at this stage of the congestion because of 
the tendency to congest the middle ear. 

Spraying or snuffing solutions into the nostrils at this 
stage is inadvisable. The throat may be gargled with 
warm physiologic saline solution, which is roughly 
represented by ^ teaspoonful of salt to half a glass of 
warm water. If the patient has been known to be 
exposed to some acute throat or nasal infection, more 
active antiseptic gargles and sprays may be used; but 
an acute coryza will rarely be aborted by local treat- 
ment. 

If the inflammation is not aborted and the second 
stage develops, that of profuse mucus and some muco- 
purulent discharge, then cleansing of the nose and 
throat becomes urgently needed. At this stage all of 
the foregoing abortive measures should cease. A 
patient who has been more or less deprived of food, 
except a small amount of liquid nourishment for from 
twenty- four to thirty-six hours, may now resume his 
normal diet. 

The more or less purulent discharge from the nos- 
trils should not be allowed to remain blocking up the 
passages. Consequently, atomizing with warm saline 
and alkaline solutions should be more or less frequently 
done. Various compound solutions or tablets for solu- 
tion are offered, but there probably is no advantage in 
these combinations over more simple ones. The sim- 
plest cleansing solution is one made from ^ teaspoon- 
ful of salt and ^ teaspoonful of sodium bicarbonate 
to a glass of warm water, or half these amounts for 



102 CLEANSING THE NASOPHARYNX 

half a glass of water. To be properly soothing, the 
solution should always be warmed. The same solu- 
tion may be used as a gargle. If a mild antiseptic is 
needed, saturated solutions of boric acid or borax are 
efficient. If stronger antiseptic solutions are required 
or advisable, hydrogen peroxid is valuable, as 1 part 
of the official aqua hydrogenii dioxidi to 4 or 5 parts 
of warm water for a gargle, or 1 part to 7 or 8 parts of 
warm water for a nasal spray. Nasal spraying and 
proper cleansing of the nose protects the adjacent 
sinuses from infection. 

Cleansing the nasopharynx by snuffing back a solu- 
tion from a teaspoon or a small vial, or snuffing back 
a spray, or gargling and then throwing the head for- 
ward and washing the nasopharynx, protects the 
eustachian tubes from infection. Two cautions should 
be suggested : first, that douching of the nasal passages 
should not be done with the nostril blocked, or with a 
high placed douch reservoir, as the pressure is likely 
to be sufficient to send fluid into the eustachian tubes 
or into the sinuses, and cause inflammation of such 
parts. Most of the patented douch apparatus are inad- 
visable. The second precaution is that it is not well to 
cleanse the mucous membrane of the nostrils too thor- 
oughly of mucus before the patient goes into the out- 
side air, especially if that air is dust-laden. The proper 
time to spray is when the patient is to remain in the 
house for a short time; or if he is sprayed and then 
must go out of doors, he may receive a non-irritant oil 
spray to furnish a coating for the mucous membrane, 
this to be used after the alkaline spray. Or a small 
plug of cotton may be placed in the nostrils. 

If the secretion from the nose is tenacious and hard 
to dislodge by blowing the nostrils, ammonium chlorid 
may be a drug of value. It has been used as a stimu- 
lant to the upper air passage mucous membrane as well 
as to the bronchial mucous membrane. It may be 
given in a simple preparation as: 



MEDICAL TREATMENT 103 

Gm. or c.c. 



I^ Ammonii chloridi 5 

Syrupi acidi citrici 25 

Aquae q. s. ad 100 



Siss 
fl.Si 
fl.Siv 



M. et Sig : A teaspoonful, in water, every three hours. 

If the coryza tends to become subacute and pro- 
longed, tonic treatment is required; a small dose of 
quinin and a small dose of iron, with or without arsenic 
and strychnin, are advisable. Or calcium glycerophos- 
phate may be given in doses of 0.30 gm. (5 grains) in 
capsule, three times a day, after meals. The following 
tonic capsule may be used, and the doses may be modi- 
fied for a child : 

Gm. 

^ Arseni trioxidi 04 

Strychninae sulphatis 04 aa gr.Ys 

Ferri reducti 10 or gr. xv 

Quininae sulphatis 2 gr. xxx 

M. et fac capsulas siccas 20. 

Sig. : A capsule three times a day, after meals. 

If the mucous membrane of the nose and throat does 
not return to health, and the secretion of mucus does 
not seem to be sufficient, a great promoter of secretion 
is an iodid, and the best salt is the sodium iodid. The 
dose required is not large; 0.10 to 0.20 gm. (Ij^ to 
3 grains) three times a day, is generally sufficient. 

Various menthol, camphor and pine oil prepara- 
tions are used as sprays or applications for the nos- 
trils, sometimes with good results, or as inhalants when 
the nostrils tend to become closed and cause discom- 
fort by occlusion. Such treatment has its use at times. 
Spraying with suprarenal solutions is sometimes of 
advantage, but sometimes is followed by more conges- 
tion. Some nose and throat specialists use suprarenal 
preparations constantly. Such treatment certainly 
many times is efficient in temporarily relieving conges- 
tion and giving comfort. 

This discussion of the treatment of common colds 
would not be complete without reference to the vaccine 
treatment. While the exact value of such treatment 
has not been determined as an abortive treatment or as 



104 ACUTE PHARYNGITIS 

a treatment that shortens the course of the disease, the 
enthusiastic recommendation of such treatment by 
some writers should be recognized. When there is 
sinus infection, autogenous vaccines would seem indi- 
cated. 

An interesting paper on the subject of vaccine treat- 
ment of common colds, including considerable bibliog- 
raphy, is that of Dr. Jessie W. Fisher.^ 

ACUTE PHARYNGITIS 

The abortive treatment of this inflammation is the 
same as that described for acute colds; but if a child 
is discovered to have a sore throat, a swab should be 
sent to the board of health for examination, and the 
child should be immediately sent home, lest diphtheria 
or scarlet fever be the cause of the condition. 

With a simple pharyngitis, soothing alkaline gargles, 
as previously described, should be the treatment. A 
very simple, pleasant and efficient gargle is as fol- 
lows: 

Gm. or c.c. 

IJ Acidi borici 2 3 ss 

Potassii chloratis 5 or 3 iss 

Aquae menthae piperitae. . . 200 fl.Svii 

M. et Sig. : Use undiluted as a gargle, every three hours. 

COUGHS 

Before discussing the infections of grip and whoop- 
ing-cough, it may not be out of place to refer to the 
varying kinds of cough. The trained nurse at the 
school, if not the teacher, should be able to note and 
describe the character of a child's cough to the medical 
inspector. Only by careful observation can the early 
stages of whooping-cough be suspected and discovered. 

Coughing is an expiratory effort caused reflexly by 
some irritation. The muscles of the lower part of the 
chest are most engaged in the act of coughing; hence 
in severe, prolonged or frequent coughing muscle tire 
occurs in the lower part of the chest, both anteriorly 

2. Fisher, J. W.: Boston Med. and Surg. Jour., June 5, 1913, p. 834. 



CAUSES OF COUGHS 105 

and posteriorly. The abdominal muscles all take part 
in this expiratory effort, and the erector spinae mus- 
cles, the serratus, and the quadratus lumborum are 
all utilized in a strong expiratory cough. These mus- 
cle contractions compress in all directions the lower 
part of the chest, and the air in the bronchial tubes 
is forced upward, and if there is no obstruction is 
expelled through the glottis. If there is obstruction, 
or even partial obstruction, the upper portion of the 
lungs, especially the apices, become dilated, and tem- 
porarily, or in severe cases, permanently, emphysema- 
tous. 

Cough can be caused by irritation of any of the 
mucous membranes of the air tract, by irritations of 
the nerves in the lung tissue, by irritations of the 
pharynx, by reflex irritation of the vomiting center, 
and by any irritation that can reach, through the 
pneumogastric nerve, the center in the medulla. From 
any of these reflex causes efferent impulses are trans- 
mitted, and the result is a cough. Irritation in the 
nose and ear may cause cough. 

Pain and muscle tire from prolonged coughing, 
besides occurring in the lower part of the chest, occur 
in the sides, low down, perhaps in the region of the 
insertion of the diaphragm, and also in the back even 
down in the lumbar region. These strong contrac- 
tions of the abdominal muscles during coughing also 
aid in temporarily diminishing the capacity of the 
thorax by pushing upward the abdominal organs. At 
the same time there is a considerable force exerted 
downward, which may tend to cause uterine displace- 
ments, hemorrhoids and even involuntary urination. 

Before this forcible expiration or cough there is 
generally a deep, quick inspiration ; then the glottis is 
partially closed and the air is propelled upward for- 
cibly, causing friction which tends to expel anything 
on the walls of the mucous membrane of the bronchial 
tubes and trachea. Even in simple bronchitis, if 
there is much coughing, there will be found increased 



106 TYPES OF COUGHS 

resonance in the apices of the lungs, as there is prob- 
ably always a temporary emphysema. 

Nasal irritations may produce cough as frequently as 
they cause asthma. Irritations of the nasopharynx and 
pharynx proper frequently cause coughing, which is 
very likely to be accompanied by retching and even 
vomiting. An elongated uvula may tickle the epiglottis 
and cause spasmodic, quick expiratory coughing. This 
cause, however, is rare compared with the frequency 
of cough caused by an enlarged lingual tonsil, whether 
the tonsil is hypertrophied, contains dilated blood- 
vessels, or is inflamed. Any disturbance of this gland 
or lymphoid tissue may cause a tickling in this region 
sufficient to produce a very irritating and disturbing 
dry cough, which comes on sometimes in paroxysms, 
until a certain amount of mucus is literally scraped off. 
The very intensity of the cough so irritates the part, 
like scratching a spot on the skin that itches, as to 
stop the tickling sensation for a time. Irritations of 
the larynx almost always cause cough. Hence no 
examination of a patient who coughs is complete with- 
out a throat and larynx observation. 

The dry bark of spasmodic croup is very character- 
istic. The noise is low pitched, and is a bark. If it 
is husky there is mucus or membrane present. 

The cough of bronchitis can be of all descriptions; 
it may be dry, may be non-productive, and may be 
moist and productive. Pain in such cough (the same is 
true of grip) is referred under the sternum, and is due 
largely to the vibrations of the air causing pain to the 
inflamed mucous membrane of the trachea and per- 
haps larger bronchi. 

The cough of pneumonia is at first somewhat pain- 
ful, and the pain is referred to the side, near the 
nipple. This cough may be at first dry, but is soon 
productive and generally should be encouraged. 

The cough of pleurisy is non-productive and unde- 
sired, and is never loud. It causes pain referred to 
the side, and is repressed by the patient. There is 



TYPES OF COUGHS 107 

nothing to expectorate, and it should be discouraged 
and stopped. 

The cough in the first stage of tuberculosis is often 
dry and catchy ; it is a hack. There is no great inten- 
sity to this cough, and no necessity for it, and it 
should be discouraged. As soon as there is much local 
bronchial catarrh the cough should, as it is then pro- 
ductive, not be discouraged, except at meals, and in 
the presence of others; that is, such patients should 
be taught when to cough. 

The cough of asthma is a wheezing affair and accom- 
panied by all sorts of rattlings ; the same type occurs 
in a stuffy, asthmatic bronchitis. This cough is gen- 
erally not harsh. 

The coughs of different individuals vary. Some 
always cough with great intensity, and others easily 
and lightly. Older persons seem to raise mucus and 
pus from the bronchial tubes with difficulty. It takes 
a great many coughs to raise the sputum for expecto- 
ration. Young children generally cough easily, but 
generally swallow their sputum. Very weak patients 
will hardly expectorate at all. In such cases the foot 
of the bed may be raised at night; also when they 
cough, while in bed, they should turn onto the side or 
stomach in order to raise the sputum, or they should 
lean over in order to have gravity aid as much as 
possible the expulsion of the mucus, etc. The cough of 
pertussis occurs in showers or paroxysms, and at the 
height of the disease the glottis closes during inspira- 
tion and the air is sucked in through a more or less 
narrow slit, giving the characteristic "whoop." 

Persons coughing very hard, as typically in whoop- 
ing-cough, but also in emphysema and in the severe 
bronchitis of strong, sturdy men, will cause a great 
deal of cardiac disturbance by retarding the flow in 
the large vessels of the thorax, thus increasing the 
work of the heart, especially of the right side. Such 
coughing can force backward the blood in the large 



108 ACUTE BRONCHITIS 

veins, thus congesting all the organs, notably the eyes, 
face and head, and whooping-cough can cause a cere- 
bral hemorrhage or a hemorrhage into the eyes. These 
patients may not infrequently have nosebleed, and 
even vomit blood. 

ACUTE BRONCHITIS 

A child with an acute bronchitis, with expectoration, 
whether with or without fever, should generally be 
sent home; or if he is not acutely sick and continues 
to attend school, he certainly should be watched. There 
is no question that, whether bronchitis occurs in an 
adult or in a child, the patient will recover more 
quickly if he remains in bed for one or more days. 

The prophylactic treatment is the same as for an 
acute coryza, and these treatments will more or less 
relieve the congestion in the bronchial tubes and pro- 
mote expectoration, if the disease is not aborted. The 
cough is at first non-productive, but as soon as mucus 
begins to be plentifully expectorated the cough is pro- 
ductive, the tightness in the chest is relieved, and the 
patient feels better. One of the best promoters of a 
free mucus secretion is ipecac, and a few drops of the 
syrup of ipecac, given every hour, unless nausea is 
caused; or from 0.03 to 0.05 gm. (about J^ to 1 grain) 
of the powdered ipecac may be given every two hours. 
The ipecac should never be pushed to the point of 
causing uncomfortable nausea. The dose should, 
therefore, as suggested, be very small. 

In the second stage of bronchitis there is no expecto- 
rant that seems to work so well as ammonium chlorid, 
and the dose should be about 0.25 gm. (4 grains) every 
two hours. The bad taste of this drug may be well 
covered up by giving it in a sour mixture, as the syrup 
of citric acid and water. If the cough is excessive and 
more than the secretion calls for, there is possibly no 
better method for its control than to give small doses 
of codein sulphate. This may be combined with the 
ammonium chlorid in a sour mixture, as : 



TREATMENT OF BRONCHITIS 109 

Gm. or c.c. 

B Codeinae sulphatis 20 gr. iv 

Ammonii chloridi 5 ^ iss 

Syrupi acidi citrici 25 fl.B i 

Aquae q. s. ad 100 fl.5 iv 

M. et Sig. : A teaspoonful, in water, every two or three 
hours. 

This prescription is for an adult, but may be readily 
modified according to the age of the child. If the 
codein is not desired, it may be omitted. If it is 
desired to give the ammonium chlorid less frequently, 
the dose may be made larger. If a sweeter mixture 
is preferred, the syrup of tolu may be substituted for 
the syrup of citric acid; or both the syrup of citric 
acid and the water may be omitted and the syrup of 
wild cherry substituted. 

If the larynx is inflamed, the inhalation of simple 
steam, or various other inhalants, may be of value, 
but a patient with laryngitis of any type should be 
under very careful observation by a physician. 

If the expectoration becomes more profuse and 
seems not to stop readily, terpin hydrate seems to be 
of value. The dose is 0.30 gm. (5 grains) about four 
times a day. This may be given in tablet or in powder ; 
solutions are unsatisfactory as it is very insoluble. If 
deemed advisable it may be combined with codein or 
heroin in small doses. There is, however, no real 
advantage in heroin over codein. 

If the coughing persists longer than a week, the 
sputum should be examined to determine what germs 
are present. If it proves to be a simple bronchitis, 
but prolonged, sodium iodid in small doses may be 
of value, especially if the patient is at all asthmatic, 
or if it is in an older person. Fresh air, good food and 
iron are always of value in curing all kinds of bron- 
chitis. If the patient is a child and the nutrition is 
poor, cod-liver oil is good treatment. A bronchitis 
that will not stop must be treated as a pre-tuberculous 
stage of tuberculosis, and the patient should receive 
climatic, or open air rest cure treatment. 



no ASTHMA 

It should be emphasized that a patient with bron- 
chitis is not properly supervised unless the tempera- 
ture is taken, and this more or less frequently. A 
patient with a fever should remain at home, if he 
wishes to avoid complications that readily occur from 
an acute bronchitis or grip. The district nurse or the 
medical inspector should always take the temperature 
of a coughing child. If a child has any fever, it should 
be sent home and the family physician summoned. 

ASTHMA 

As previously mentioned, a child in school that is 
found to be asthmatic should be carefully examined 
by the medical inspector and referred to the family 
physician, and if necessary, to a nose and throat spe- 
cialist, to determine whether or not there is a reflex 
cause, and to have this cause removed if possible. 
The asthmatic habit once well acquired is difficult to 
cure. 

influenza: grip 

Since the last epidemic of this disease in the United 
States in the winter of 1889 and 1890, there has been 
no year without the disease occurring in many parts 
of the country. In some regions it is present for 
months, sometimes occurring in small epidemics, at 
other times in isolated instances. Were the air-passage 
secretions to be examined in every case of cold and 
bronchitis, the influenza bacillus of Pfeiffer, dis- 
covered by him in 1892, would frequently be found. 

While the well-known acute epidemic types of this 
disease probably always show this bacillus, it is not 
always discovered in instances that seem similar and 
are well termed grip or influenza, as distinct from an 
ordinary cold or bronchitis. Whether another distinct 
germ causes an inflammation of the air passages simu- 
lating influenza (that is, a closely related germ), or 
whether it is the same germ that has become so atten- 
uated and changed that it is not recognized, has not 



INFLUENZA— GRIP HI 

been determined. To all intents and purposes, clin- 
ically and practically, these isolated cases without the 
true Pfeiffer bacillus should be considered as serious 
as though that germ were present and should be treated 
the same, as all of these cases seem readily to develop 
pneumonic conditions. 

The toxin produced or elaborated by the influenza 
bacillus seems to be a vasomotor depressant, and per- 
haps acts through the sympathetic system. The small 
blood-vessels all over the body seem to dilate and pro- 
duce capillary congestion, especially of the mucous 
membranes, the most frequent result being a coryza, 
a pharyngitis, a laryngitis or a tracheitis. The con- 
gestion in the larynx causes the harsh, dry, metallic 
cough which is quite characteristic of this type of 
influenza. The congestion and swelling of the mucous 
membrane of the trachea causes a peculiar oppressed 
feeling, with more or less pain, referred to the upper 
part of the sternum. The great amount of sneezing 
which occurs with a typical attack, almost similar to 
hay-fever, is due to congestion of the mucous mem- 
brane of the nostrils. The conjunctivae may also be 
injected, causing pain in the eyeballs and often a ser- 
ous conjunctivitis, another typical symptom of influ- 
enza. In some seasons there seems to be a special 
tendency to middle-ear inflammations. At other times 
there frequently occurs a congested drum, with some- 
times a hemorrhagic bleb or vesicle on the drum, a 
very painful though easily remedied condition. 

The almost constantly present lumbar backache at 
the onset of this disease is probably due to congestion 
of the kidneys, and albumin is frequently found in the 
urine of such patients, and occasionally blood-cor- 
puscles. A menorrhagia or a metrorrhagia may occur 
from the same tendency to dilatation of the blood- 
vessels. There may even be nosebleed, and occasion- 
ally a slight hemoptysis without any other assignable 
cause and without any subsequent development of 



112 TYPES OF INFLUENZA 

tuberculosis or any other disease. With this disease, 
although the fever may be high, the skin is likely to 
be moist, and there may be profuse perspiration. The 
pulse may be slower than we normally expect from 
the height of the fever, and the blood-pressure is gen- 
erally lowered; all of these conditions are due to the 
tendency of the blood-vessels to dilate. This dilatation 
of the vessels on the surface of the body, with the 
increased radiation and evaporation, causes the begin- 
ning high temperature of typical influenza to be short- 
lived, although for some days the temperature may 
rise regularly every afternoon and evening to a grad- 
ually decreasing degree. 

The heart is generally weak from start to finish in 
this disease, and even collapse turns can occur. Also, 
during the first year of the last epidemic many persons 
were shocked by the disease and collapsed, having no 
fever and showing no symptoms except a weakened 
heart and circulation. This is the typical nervous type 
of the disease. The disease may also cause cerebral 
symptoms without many catarrhal symptoms, and 
sleeplessness, irritability and headache are very con- 
stant symptoms in all forms of grip; even meningitis 
can occur from this germ. 

Rather an infrequent type of the disease is the bowel 
type; this can occur without respiratory catarrhal 
symptoms. Patients so affected have diarrhea, with 
more or less intestinal irritation, apparently the great- 
est amount of dilatation of blood-vessels in these cases 
occurring in the mucous membrane of the intestinal 
tract. These various types, the catarrhal, the nervous 
and the abdominal, may be interwoven, and a patient 
may show symptoms of all three. 

The future of every case of influenza is prostration, 
nervous and muscular debility, with more or less cir- 
culatory weakness ; in other words, there is exhaustion. 
The patient's resisting power is reduced, and any 
defect or diseased condition that he may have is aggra- 
vated by an intoxication with this germ. 



COMPLICATIONS OF INFLUENZA 113 

If no complications occur, the convalescent patient 
should rest as much as possible, should not be sub- 
jected to exposure and should be given tonics, and, if 
necessary to cause restful sleep, for a short period at 
least, some hypnotic or some physical method of caus- 
ing sleep. The most frequent complication is pneu- 
monia, and the type of pneumonia that the influenza 
germ seems to cause most frequently is the lobular or 
bronchial pneumonic type ; pneumonic congested areas 
may be found in different parts of one or both lungs. 
Not infrequently, however, true lobar pneumonia 
occurs. 

The next most frequent complication, as suggested 
above, is middle-ear catarrh. The various sinuses in 
the region of the nostrils may become affected; all 
types of indigestion may occur, and not only sleepless- 
ness and meningismus, but also a very serious menin- 
gitis, and even insanity can be caused by these germs 
and their toxins. Mental depression is a common 
occurrence, following severe attacks of grip. Peri- 
carditis and endocarditis occur as complications of 
influenza. 

It is thus seen that this disease should always be 
taken seriously, and every possible means used to pre- 
vent contagion, as it is one of the most highly con- 
tagious diseases. It spreads with great rapidity, but 
only by contact, although it may doubtless be trans- 
mitted by infected clothing, and perhaps even by let- 
ters, as when the last epidemic first reached America, 
the first persons affected in many cities were post- 
office clerks. 

While no season is exempt from this disease, it 
occurs most frequently in colder weather, and in the 
colder climates, and in moist climates. Perhaps the 
more sunshine, the less frequent the disease. While 
one attack may protect a person for that season, he 
seems more susceptible to subsequent attacks in fol- 
lowing years. There are doubtless many carriers of 



114 TREATMENT OF INFLUENZA 

this disease who may have a persistent and continued 
subacute or chronic catarrhal infection and very likely 
are distributers of the disease to others. When one 
case occurs in a household, other members of the 
family become readily infected. The same is true in 
schools and in stores or buildings in which an infected 
person is closely associated with others. Many an 
office with one employee affected will soon, on investi- 
gation, show every other employee to be more or less 
seriously affected. While almost all persons are sus- 
ceptible to this disease, a few seem to be immune. 
It is the most frequent of all definite infectious dis- 
eases. 

TREATMENT 

It having been determined or suspected that a 
patient has influenza, it is much more important that 
he remain in bed, or at least in the house, than if he 
has an ordinary acute cold. Also, it is more essential 
that he be more or less isolated or that measures be 
taken that he does not spread the disease by spraying 
from coughing or sneezing, and that he does not use 
the same towels, napkins, drinking-cups and eating 
utensils as other members of his family. The patient 
should be prohibited from fondling and kissing chil- 
dren. If the patient is a young child in close contact 
with the mother or nurse, all possible precautions to 
prevent contagion should be taken. 

In a word, each family should be taught that grip 
is an infection, that it is contagious, that it spreads 
rapidly, that it may have serious complications and 
that it frequently leads to pneumonia, which has 
become in many regions of this country the most fre- 
quent cause of death. Therefore, even an apparently 
mild case of grip or influenza should be treated actively 
and energetically. As previously stated, whether a 
schoolchild begins with an acute cold or an influenza, 
he should be sent home and remain there until he is 
well, or at least almost well. 



TREATMENT OF SYMPTOMS 115 

As a grip patient is liable to have a chill, or at least 
feel chilly or have cold sensations up and down the 
back, anything that makes him warm improves his 
condition. He may be given hot malted milk, hot tea 
or hot lemonade, at more or less frequent intervals, 
until his chilliness has ceased. The patient may be 
given a hot tub bath and then put into a warm bed in 
a warm room as an efficient means of making him 
comfortable and relieving his internal congestions. 
Hot water bags at the feet and extra coverings to the 
bed are often needed. A quickly acting stimulant is 
aromatic spirits of ammonia, given in half teaspoon- 
ful doses in hot water or hot lemonade, at intervals of 
three hours, for three or four times. The various 
methods suggested for aborting an acute cold may be 
used in this disease. Much greater care must be exer- 
cised, however, if the patient has the influenzal infec- 
tion than if he has a simple cold, as to when he can 
return to his work or occupation, or be subjected to 
exposure to cold or dust, either in a house, building or 
outdoors. 

As soon as the patient feels warm, the temperature 
may rise quite high, associated with severe headache, 
backache and irregular pains in other parts of the 
body. At this time a drug such as acetanilid, antipyrin, 
acetphenetidinum, or acetylsalicylic acid will be of 
benefit, provided that the patient is not ambulatory, 
and that he is not to be subjected to exposure. With 
this depressing infection such treatment is not wise 
unless a patient is in bed, or at least remains in the 
house. 

The proper dosage of these drugs has already been 
suggested, and no one of them should be long con- 
tinued. The most depressant is undoubtedly acet- 
anilid, and perhaps the least depressant is acetphen- 
etidinum. Should depression occur after one of these 
drugs has been administered or from the disease, cir- 
culatory stimulants such as aromatic ammonia, cam- 



116 MEDICAL TREATMENT 

phor or caffein should be given and the patient sur- 
rounded with dry heat. A hypodermatic injection of 
strychnin sulphate, %o gi"ain, may be given to stimu- 
late the nerve centers. Cyanosis has not infrequently 
been caused by acetanilid^ but an amount of this drug 
large enough to cause such a condition should never be 
given. The following prescription may be suggested: 

Gm. 

B AcetanilidI 0150 gr. viiss 

Sodii bicarbonatis 1 10 gr. xv 

M. et fac chartulas 10. 

Sig. : One powder, with water, every two hours, except 
when the patient is sleeping. 

Or: Gm. 

IJ Acetphenetidini 1 150 

Phenylis salicylatis 1 1 50 aa gr. xxv 

M. et fac chartulas 5. 

Sig. : One powder every three hours. 

It should be remembered, as previously noted, that 
it has been shown that an alkali like sodium bicar- 
bonate inhibits the undesired action of coal-tar drugs 
on the heart ; also, that caffein does not protect a heart 
from undesirable activities of the coal-tar drugs; in 
fact, it has been shown to intensify such activity. 

In making a diagnosis of the infection present it 
is well to remember that any of these drugs, and also 
salicylic acid in any form, may cause eruptions on the 
skin, either erythematous or urticarial. 

But little food is needed during the first twenty- 
four hours of grip, and it should not be pushed even 
on the second day, if food is repugnant to the patient. 
He should have plenty of water and such simple liquid 
nourishment as he desires. As soon as the appetite 
returns, food should be pushed. The various catarrhal 
conditions should be treated as suggested under coryza, 
pharyngitis and bronchitis. Also, while the patient is 
kept warm, he should have good fresh air in his room. 
This is essential with all infections, and especially 
with infections of the nose, throat and lungs. The 
bowels should be treated as indications call for. Simple 



CONVALESCENCE 117 

laxatives may be given, if needed, or the soothing 
bismuth subcarbonate, if there is intestinal inflamma- 
tion. Phenyl saHcylate (salol) may be given, if there 
is much fermentation in the bowels, or the Bulgarian 
form of lactic acid bacilli m.ay be given for a few days. 

As soon as the patient begins to convalesce, he 
should be given tonics, and if there is no inflammation 
in the ears, quinin is valuable. Some form of iron 
should generally be given, and possibly a bitter tonic 
before meals. If the patient is not nervous, a small 
dose of strychnin three times a day is good treatment. 
On the other hand, it should be urged that strychnin 
stimulation is overdone, and a patient who cannot sleep 
should not be given strychnin or quinin later than the 
noon meal. Sometimes the sleeplessness following 
influenza is benefited by the administration of one-half 
to one teaspoonful of good fluidextract of ergot, taken 
an hour before bedtime. These patients should never 
be allowed tea or coffee after the noon meal, as they 
are very susceptible to cerebral stimulation by caffein 
and are likely to remain awake for hours from such 
stimulation. All disturbances or diseased conditions 
left over by grip must be treated energetically, else 
they tend to be prolonged. There are few germs that 
seem to be so tenacious and persistent, at least in their 
unpleasant results, as is the influenza bacillus. All 
persons are susceptible to serious consequences from 
influenza. 

A schoolchild's desk, pencils, etc., and immediate 
surroundings should be thoroughly cleaned after the 
child has been sent home with an acute cold of any 
kind. This is especially necessary in cases of influenzal 
infection. 



HOOKWORM DISEASE 
( Uncinariasis) 



This disease is found in all tropical and southern 
temperate zones ; in the United States southward from 
the Potomac River latitude through to the Pacific 
coast. The symptoms are laziness, lassitude, weakness, 
loss of physical and mental ability and vitality, loss of 
weight and anemia. Children do not properly grow 
and adults become shiftless, incompetent, and poverty 
stricken, and they, with their families, become a tax 
on the community. Hence hookworm eradication is 
an economic question. 

Hookworm disease is said to go back to ancient 
Egyptian times, but the parasite was not found until 
1838, by an Italian; its relation to anemia was not 
discovered, however, until 1877, by Grassi and Colo- 
miatti. It was named Ankylostoma duodenale. 

The hookworm was discovered in Porto Rico by 
Major Ashford, Surgeon of the United States Army, 
but to Dr. C. W. Stiles of the United States Public 
Health Service belongs the honor of having found the 
worm in the southern states and of having shown 
that it differs generically from the Old World worm, 
but that it causes the same symptoms. The American 
type of worm is called Necator americanus. 

Not to go into the life history of this parasite, 
suffice it to say that it may live in large numbers in 
the intestines of human beings for years, not only 
feeding on the blood and using up its nutriment, but 
biting the intestinal walls and causing hemorrhages, 
and by both means producing a progressive anemia. 
Eggs from these worms pass off with the feces, grow 
into minute larvae in the soil so contaminated, enter 
another human intestine, rarely by means of infected 



MMHHHHttilMaMHMlMMMMII 



HOOKWORM DISEASE 119 

food such as uncooked vegetables and fruit. In the 
majority of cases the larvae pierce the skin of the 
leg or other part exposed to contaminated feces and 
reach the intestine. In this way a barefooted child 
or adult may acquire infection through exposure of 
his feet. 

The excrement of carriers of the disease must never 
be allowed to infect the soil. Also every carrier must 
be discovered, and it is the duty of each community 
to discover and treat every carrier within its confines, 
and even to be suspicious of visitors. 

The establishment of sewerage systems in cities 
should eradicate the disease from those localities. 
Compelling the erection and use of sanitary privies, 
be they ever so inexpensive and simple, is another 
necessary preventive measure outside of sewered 
towns. An old-fashioned privy, wherever found, 
should be abolished. Its odors are offensive, it breeds 
flies and contaminates the soil, and the drainage may 
reach water-supplies. A privy to be modern and 
sanitary should be properly ventilated and well 
lighted, but thoroughly screened with fine-mesh copper 
wire, to prevent flies and mosquitoes from entering 
the building. The building should be firmly cemented 
to the foundation; there should be no leaks or open- 
ings. There should be a hinged door in the rear, 
opening under the seats for cleaning purposes. The 
seat covers should be self-shutting. The excreta 
should be received into a water-tight box or pail, and 
whether the wet or dry system is selected is a matter 
for the decision of the local health authorities. Just 
what disinfectants shall be used, chlorinated lime, or 
phenol (carbolic acid) solutions, or some oil that 
repels flies and other insects, is also for the decision 
of the local board of health. The sanitary privies 
recommended by the United States Public Health Ser- 
vice will be found described in United States Farmer's 
Bulletin 463. 



120 TREATMENT OF HOOKWORM DISEASE 

Another preventive of infection by hookworm is to 
insist that shoes be worn in all infected regions. 

The disease can be discovered by giving the specific 
treatment in a suspected case and then sifting or 
washing the stools through cheese cloth, when worms 
will be found, if present. 

The treatment is to give little or no supper, and 
at bedtim^ a dose of magnesium sulphate. In the 
morning, as soon as the bowels have moved freely, 
one-half the dose of thymol, in capsules, is given, and 
in two hours the remainder of the thymol. Two hours 
later another dose of magnesium sulphate is admin- 
istered. After movements of the bowels from this 
dose food may be taken, but only coffee or tea, with- 
out milk, should be allowed during the period of the 
treatment, namely, until the thymol has supposedly 
all passed out of the body. Absorption of thymol is 
not desired, as it may cause unpleasant symptoms. 
Alcohol and oils should not be given either before, 
during or even soon after the treatment. For one 
hour after taking the thymol the patient should lie 
on his right side to hasten the passage of the drug 
and liquid through the pylorus into the intestines. 

The dose of thymol depends on the age, but is large. 
Ferrell^ suggests 4 gm. (60 grains) for an adult dose 
(that is, from 20 years of age upward). Doses for 
children and youth may be readily estimated by the 
following formula, namely: At 15 years, ^ of the 
age, ^ of the adult dose; at 10 years, >4 the age, 
Yz the dose; at 5 years, ^ the age, J4 the dose; at 
2^ years, J^ of the age, J^ of the dose. If the 
patient is much underweight for his age, the dose 
should be reduced accordingly. The thymol should 
be powdered and placed dry in capsules. One-half 
the dose decided on is given at 6 a. m. If the bowels 
have been well moved from the dose of magnesium 
sulphate of the night before, the other half of the dose 

1. Ferrell, John A.: Hookworm Disease, The Journal A. M. A., 
June 20, 1914, p. 1938. 



USE OF THYMOL 121 

of thymol should be given at 8 a. m., both doses being 
taken with plenty of water. Ferrell adds sugar of 
milk in equal parts to the thymol, and says he thinks 
the drug acts better. 

In one or two weeks the treatment should be 
repeated, unless the microscope shows the feces to be 
free from the parasite and its eggs. Sometimes a 
third and even a fourth treatment may be needed. 
The action of the thymol may be hastened by (at the 
moment of swallowing) uncapping the capsules. 

Thymol when absorbed acts like phenol, but it is 
slowly dissolved by the gastro-intestinal fluids and 
hence, is absorbed slowly. Any oil or fatty substance 
hastens its absorption. Convulsions are probably not 
often caused by thymol poisoning, but great weakness 
and finally collapse are the gross subjective symp- 
toms. Objective symptoms of its undesired absorption 
are albumin and even blood in the urine. Fatty 
degeneration of the liver and congestion of the kid- 
neys and lungs are pathologic findings. 

To forestall any possible great absorption of thymol 
after large doses are administered in hookworm dis- 
ease, a brisk cathartic (Epsom, Glauber's, or Rochelle 
salt) should be given and repeated, if free catharsis 
does not occur within a few hours after taking the 
thymol. Castor oil, or any other oil, should of course 
not be the cathartic used. If symptoms of poisoning 
occur, stomach-washing, colon-washing, and sodium 
sulphate or potassium and sodium tartrate should be 
the means used to promote elimination. Strong black 
coffee should be given, and hypodermic injections of 
atropin, strychnin, and pituitary extract should be 
administered and the patient should be surrounded by 
dry heat. Later, any kidney congestion should be 
treated as an acute nephritis. 

Except as a specific for hookworm, thymol should 
probably never be used internally. As a bowel anti- 
septic it is too dangerous a drug to be used repeatedly, 
unless the dose is too small to be of any value. 



122 USE OF OIL OF CHENOPODIUM 

Ferrell's dosage for adults for hookworm disease 
is as follows: 

gm. 

IJ Thymolis 41 or gr. Ix 

Fac capsulas siccas 10. 

Sig. : Take 5 capsules, with plenty of water, in the early 
morning, as soon as the bowels have moved. Take the 
other 5 capsules in two hours. Two hours later take ^ ounce 
of Epsom salt, which should be repeated if it does not act 
in four hours. 

Owing to a possible scarcity of thymol it is impor- 
tant to note that investigations of the United States 
Public Health Service have shown that oil of cheno- 
podium (American wormseed oil) is efficient in this 
disease. (Public Health Reports, reprint No. 224, 
Oct. 2, 1914, by M. G. Hotter.) 

Wormseed oil seems to paralyze or stupefy rather 
than kill the hookworm; therefore it is very essential 
that soon after such action has occurred, a cathartic 
should be administered to cause evacuation of the 
worms before they can recover their vitality. Unlike 
male fern and thymol, castor oil may be administered 
with this drug. It will be remembered that any oil is 
likely to cause a dangerous amount of male fern and 
thymol to be absorbed. This is not true of wormseed 
oil. 

The doses of oil of chenopodium suggested in this 
pamphlet are about 1 drop for every year of age up to 
fifteen. The drug is well administered in a teaspoonful 
of granulated sugar, every two hours, for three doses. 
Two hours later, a child of ten years, for instance, 
should receive a tablespoonful of castor oil with one- 
half a teaspoonful of spirits of chloroform. The dose 
of the castor oil and of the chloroform should vary 
according to the age of the patient. 

Possible undesired symptoms from wormseed oil are 
drowsiness and depression. Such symptoms occurring, 
rapid purging should be caused by a saline cathartic, 
and such stimulants as hot coffee or caffein should be 



HOOKWORM DISEASE 123 

given. The pamphlet suggests hot coffee by the rec- 
tum, but while purging is going on, this would hardly 
seem worth while. 

The pamphlet further suggests that physicians using 
this wormseed oil treatment should keep careful record 
of their cases and report their results. 



WHOOPING-COUGH 



This infection, which most frequently attacks chil- 
dren, is generally regarded by the public as a trivial 
disease, and consequently proper treatment and means 
of prevention of infection of others are frequently not 
instituted. Even the medical profession for many 
years did not consider the disease serious, but better 
statistics, demonstrating the causative agent of death- 
dealing complications, have shown that whooping- 
cough is a dangerous disease. 

The greatest mortality of whooping-cough is indirect. 
A large number of those infected die of such complica- 
tions as bronchial pneumonia, capillary bronchitis, 
tuberculosis and a few from hemorrhages, while 
chronic debility, anemia, emphysema, and some lesion 
of the central nervous system are of not infrequent 
occurrence. According to the United States Public 
Health Reports, in 1910, whooping-cough had a mor- 
tality of 11.4 per hundred thousand deaths, while 
scarlet fever had a mortality of 11.6, measles 12.3, and 
diphtheria 21.4. In young children and infants, 
whooping-cough causes more deaths than measles, and 
some statistics show twice as many deaths as measles ; 
95 per cent, of deaths from whooping-cough occur 
during the first five years of life, and the majority of 
these during the first two years.^ The conclusion is 
self-evident that babies and young children must not 
be allowed to acquire whooping-cough if it is possible 
to prevent it. If the deaths which occur from the dis- 
eases which follow as complications from previous 
whooping-cough were properly recorded as secondary 

1. Morse: Whooping-Cough, The Journal A. M. A., May 31, 1913, 
p. 1677. 



CAUSE OF WHOOPING-COUGH 125 

to whooping-cough, the seriousness of this disease 
would become even more evident than present statistics 
show. 

There is no doubt that this disease is due to a con- 
tagium, and that this contagium is contained in the 
sputum and secretions of the upper air tract, and is 
transmitted to others by more or less close contact, 
either by droplets from spraying in sneezing or cough- 
ing, or by contact with infected handkerchiefs, napkins 
or bedclothes, or by contact with freshly sprayed or 
infected books, pencils, desks, chairs or eating utensils. 
Doubtless a frequent method of acquiring the disease 
is by kissing. 

It is pretty well proved that the Bordet-Gengou 
bacillus is the cause of this disease. It seems to be 
established that the greatest infectivity occurs during 
the initial stages of whooping-cough, and that even 
during the active paroxysmal stage there is less lia- 
bility of infection of others, and in the later stages 
there is probably no infective agent present. Some 
investigators even assert that a child should be allowed 
to return to school long before the paroxysmal stage 
is over, but that other children in the family of the 
child affected should not be allowed in school until it 
is shown that they will not have the disease. The 
disappearance of the infective bacillus and the conse- 
quent lessened danger of giving the disease to others 
seems to occur because some antibodies develop that 
prevent the further growth of the germ. It is cer- 
tainly interesting that this contagious disease ceases to 
produce its contagium long before the symptoms of 
the disease have disappeared or the evident disease has 
ended. Whether or not this will be found true of 
scarlet fever and measles is of course not yet known, 
but it is markedly different from typhoid fever, pneu- 
monia and diphtheria, in which the specific germs tend 
to persist a long time. 



126 TRANSMISSION OF WHOOPING-COUGH 

It has been shown that some domestic animals may 
be experimentally infected with whooping-cough ; how 
frequently such animals become accidentally infected 
and are able to transmit the disease to children is not 
known. Probably, however, such a source of infec- 
tion is rare. Kittens, puppies and monkeys have been 
experimentally infected with this germ. 

Mallory and Horner^ confirmed the opinion that the 
Bordet-Gengou bacillus is the cause of the infection of 
whooping-cough. This is a minute bacillus, occurring 
in large numbers among the cilia of the epithelial cells 
of the mucous membrane of the trachea and bronchi. 
It is stated that the germ does not grow above the 
larynx, although of course by coughing it reaches these 
parts. This germ is a small coccobacillus, and resem- 
bles the bacillus of influenza. 

This disease is so readily acquired from one infected 
that some boards of health not only prohibit children 
who have it from attending school, but also prohibit 
their attending Sunday schools or public congrega- 
tions, riding in public conveyances, playing in public 
parks, playing with other children on public squares, 
and from entering stores and theaters. Not to cause 
these children to be isolated in their homes, when 
fresh air is of great benefit to them, the boards of 
health of certain cities order that the child shall be 
tagged in some manner, perhaps with a button on 
which "whooping-cough" is printed in plain lettering. 
Just how carefully such ordinances will be carried 
out, and just how much they will reduce the frequency 
of whooping-cough, will be determined after full trial. 

This disease occurs largely in epidemics, and young 
children and babies are apparently most susceptible to 
the disease. This may be more apparent than real 
from two reasons : first, because young children, neces- 
sarily remaining more in the house, are liable more 

2. Mallory and Horner: Jour. Med. Research, November, 1912. 
Mallory: Jour. Med. Research, March, 1913. 



DIAGNOSIS OF WHOOPING-COUGH 127 

frequently to come into contact with concentrated 
infected matter if an infected person comes near them, 
and secondly, because a large number of older children 
and the majority of adults have probably had the 
infection and have become immune. However, when 
an adult or elderly person acquires the disease it is 
almost invariably severe. The muscular strength of 
adults makes the paroxysmal coughing of much greater 
danger; they are more liable to emphysema, heart 
strain and hemorrhage. They are not so liable to have 
pneumonic complications. Whooping-cough, however, 
even in adult life, is a not infrequent stimulator of a 
latent tuberculosis. Often an adult, who is in close 
contact with a whooping-cough patient, and who may 
have had the disease in childhood, develops a mild 
form of the disease; at least they have the catarrhal 
symptoms and cough spasmodically occasionally. 
Whether the Bordet-Gengou bacillus is present in 
these cases has not been determined. It is a fact, how- 
ever, that ordinarily one attack of the disease renders 
a person immune. 

From the foregoing it will be seen how very impor- 
tant it is to make an early diagnosis of whooping- 
cough. While it is stated that the Bordet-Gengou 
bacillus may be generally demonstrated in true cases, 
a method termed the "complement-deviation" test is 
urged by some investigators. When positive, it is 
almost conclusive evidence of the disease being present, 
and when negative conclusive evidence that the disease 
is not present. Friedlander and Wagner^ make the 
statement that in their opinion *'the complement- 
deviation test is of the greatest possible value in the 
diagnosis at all stages." A description of the technic 
of this test is given by them.^ 

As both the identification of the Bordet-Gengou 
bacillus and this complement-fixation test require con- 

3. Friedlander, Alfred, and Wagner, E. A.: Diagnosis of Whooping- 
Cough by the Complement-Deviation Test, Am. Jour. Dis. Child., 
August, 1914, p. 134. 



128 PATHOLOGY OF WHOOPING-COUGH 

siderable time and skilled technic, examination of the 
blood for leukocytosis is suggested as a quicker method 
of determining whether or not the disease is present. 
A small leukocytosis, from nine to ten thousand, may 
be present as early as the third day, while during the 
paroxysmal stage it may run up to sixty thousand or 
more. It has been considered that in a suspected 
patient a leukocytosis from fifteen to thirty thousand 
(other diseases that cause leukocytosis being excluded), 
combined with catarrhal symptoms and the opportunity 
for infection, would give presumptive evidence that 
the disease developing is whooping-cough. In this 
leukocytosis there is a relative increase of lympho- 
cytes. It is stated that this leukocytosis may be more 
or less present for from two to three months, and 
that in the stages of improvement a mild eosinophilia 
is found.* While leukocytosis is generally present in 
v/hooping-cough, its diagnostic importance must 
always be modified by the possibility that some other 
cause of this increase in white cells is present. It 
should also be remembered that leukocytosis is often 
present in young children from various causes. 

The incubation period of pertussis is not definitely 
known, and may vary from two to ten days ; therefore 
before it is considered safe for a child exposed to this 
infection to return to school or to play with other 
children, at least ten days must have elapsed, and 
perhaps a better working rule is two weeks. 

Pathologically, the disease manifests itself by a 
catarrh of the upper bronchial tubes, trachea, larynx 
and perhaps pharynx and nose. The secretion is 
mostly mucus, with perhaps, later, a mucopurulent 
discharge from secondary infections. There are con- 
ditions, moreover, caused by a severe paroxysm of 
coughing, or by a prolongation of these paroxysms, in 
other words, hemorrhages; perhaps more or less 

4. Kolmer, J. A.: The Diagnostic Value of a Blood Examination in 
Pertussis, Am. Jour. Dis. Child., June, 1911, p. 431. 



TREATMENT OF WHOOPING-COUGH 129 

emphysema; always cardiac strain, and perhaps car- 
diac dilatation ; and, if frequent or repeated coughing, 
anemia and emaciation. Hemorrhages may occur from 
the nose, in the eyes, or even in the brain. 

The cough is laryngeal in type, is at first dry, and 
later becomes spasmodic and paroxysmal, thus differ- 
ing from that of ordinary colds; that is, the coughs 
occur in series, more or less periodically, or in showers. 
With these paroxysms there is more or less closing 
of the larynx, with the attempt at inspiration through 
a narrowed glottis, which causes the characteristic 
whoop. These paroxysms increase in frequency as the 
disease progresses, and are precipitated by any change 
in the atmosphere and by suddenly breathing in cold 
air, as by laughing, and even by swallowing food, and 
they sometimes occur without any apparent cause, 
because of irritation from the germ and its conse- 
quences. The number of paroxysms in twenty-four 
hours varies, but there may be as many as fifty. 
Early in the disease there may be a slight fever. 

TREATMENT 

Unless the patient has considerable rise of tempera- 
ture, it may not be necessary to put him to bed, but, 
especially with children, the paroxysms are generally 
diminished if the child is kept in bed for a time, or at 
least kept quiet. The more active the child, the more 
paroxysms. Consequently, even without fever, if a 
child vomits almost every meal, or if he coughs so 
severely as to cause hemorrhages, or shows that the 
right side of the heart is becoming strained (which is 
the side of the heart most affected), he must be put to 
bed and remain there. 

In most communities a schoolchild with whooping- 
cough is immediately sent home. In only a certain 
proportion of communities as yet is whooping-cough a 
reportable disease. There is no question that it should 
be reported; that the child affected should be isolated 



130 PREVENTION OF WHOOPING-COUGH 

as much as possible ; that the infection of others should 
be prevented, if possible, and that other children in the 
same family and perhaps in the same household or 
tenement, who are attending school, should be sent 
home until the period of incubation is past, dating 
from the last contact with the infected patient. 

The methods of contact have already been suggested, 
and it is needless to emphasize the necessity for the 
school authorities to cleanse and clean the desk, chair 
and immediate surroundings of the child, and the 
books, pencils, etc., that he used. Also the children 
who sat in close relationship to this infected child 
should be watched by the medical inspector, or, per- 
haps, scientifically examined, as suggested above (that 
is, throat secretions and blood) and those who show 
any signs of infection should be sent home until it is 
shown that they have not become infected. These 
preventive measures seem almost too severe or too 
great for a disease that has been considered so simple, 
but, as previously stated, the disease and its results 
in preventive medicine will be in diminishing this dis- 
are not simple, and the number of deaths among young 
children is very great. One of the greatest advances 
ease that has been so long neglected. 

Instruction should be given by the physician to the 
mother, or whoever cares for the child with whooping- 
cough, as to how the prevention of infection of others 
should be carried out, such as the care of handker- 
chiefs, napkins, etc. In communities where the disease 
is reportable, the board of health should send instruc- 
tions to the family. 

The actual treatment of this disease may be divided 
into four heads : (1) to prevent the infection of others ; 
(2) to shorten the disease, if possible; (3) to diminish 
the severity of the paroxysms ; (4) to treat complica- 
tions as they occur. 

The first indication has already been considered. 



HYGIENE AND NUTRITION 131 

The second indication is met by general hygiene and 
by drugs. Fresh air and sunshine, without exposure, 
are among the greatest mitigators of this disease. If 
the weather is pleasant, the child should be out doors 
or on a veranda most of the time. A child does much 
better in the country or at the seashore, if the season 
and circumstances will allow it. If the child is too 
sick, or the weather is such that it is impossible to 
remain outdoors, he should be isolated in one, or 
better, in two large rooms, so that while one room is 
being thoroughly aired and cleansed he may go to the 
other one. There seems to be no question that the 
more infected or polluted the atmosphere of a room, 
the more the child will cough. Whether such an 
atmosphere simply irritates, or he reinfects himself 
instead of having his infection diminished, is unimpor- 
tant. The fact remains that the ventilation must be 
excellent to diminish the frequency of the paroxysms. 

Another important factor is nutrition. If the child 
vomits a meal as soon as he has eaten it, during a 
paroxysm, in a few minutes he should be given food 
again, with the probability that the next paroxysm will 
not so quickly occur but that the food may remain in 
the stomach and be digested. A child that receives 
insufficient nourishment from any reason should be 
given food more frequently. The character of the 
food should depend on his condition, and should be 
that which is found to be less frequently vomited. The 
best diet is cereal and vegetable, with milk and eggs. 
The end-products of meat metabolism are likely to 
raise the excitability and irritability of any one whose 
nervous system is irritated. For this reason meat 
should not be given, and no tea or coffee. A patient 
who is not allowed meat should receive a small dose of 
iron once or twice a day. Calcium in any simple form 
may be used as a nervous sedative and a nutrient. Hot 
baths before going to bed relax the nervous system and 
quiet the patient. Also massage is sometimes soothing. 



132 SPRAYS AND GARGLES 

Of course, it is always essential to have the bowels 
move daily. Plenty of water should be given the child, 
as the more moist the mucous membranes, the less they 
are irritated, and the less frequent the paroxysms. 
For this object many inhalants have been advised. 
Perhaps the most important element of these inhalants, 
whether sprays or steam, is the water that they con- 
tain. Sometimes bland petroleum oils atomized and 
inhaled soothe the irritated mucous membranes. 

Various antiseptics have been suggested. The most 
frequently used is perhaps phenol (carbolic acid) in 
some form, and very popular has been the vaporization 
of a phenol combination in the atmosphere of the 
room. There is no question that phenol tends to 
benumb peripheral nerves. If much phenol was 
absorbed it would disturb the kidneys. Exactly what 
are the germicidal constituents or powers of such 
inhalants has not been determined. Phenol sprays 
have been used in from 0.5 to 1 per cent, strength. 
Antipyrin as a spray and gargle has been much used 
as a germicide in from 5 to 10 per cent, strength, and 
has been much lauded in this disease. Quinin sprays, 
though more disagreeable, have been used in the throat 
as germicides. Various combinations with thymol and 
eucalyptol, and other mild aromatic antiseptics, have 
been used as sprays and gargles or inhalants. It is 
quite probable that a creosote or other antiseptic 
inhalant may inhibit the growth of germs in the 
trachea and upper large bronchi, provided the patient 
is old enough to cooperate and inhale the vapor into the 
lungs to that depth. As an application in the pharynx 
and mouth, hydrogen peroxid solutions, 1 : 5, would be 
as efficient as anything that could be offered. Many 
times, however, these "antiseptic" inhalants or atomiz- 
ing substances cause irritation and paroxysms, and 
must be abolished, while mild alkaline solutions, well 
represented by ^ teaspoonful of sodium chlorid and 
34 teaspoonful of sodium bicarbonate in a glass of 



VACCINES IN WHOOPING-COUGH 133 

warm water, cleanse and soothe the throat without 
causing paroxysms. 

There are still many who believe that quinin given 
internally will shorten the disease. It has not yet been 
shown that quinin' inhibits the growth of the Bordet- 
Gengou bacillus. If there is any tendency to secondary 
infection in the nasopharynx, with congestion of the 
ears, of course quinin should not be given. 

Also, to meet this indication and shorten the disease 
is the vaccine treatment. The exact value of vaccine 
in this disease has not been demonstrated. 

SilP made a study of this treatment in whooping- 
cough, and found that the dose of the bacillus should 
be 50 million, and this dose given every other day in 
ordinary cases, and every day, or 100 million every 
other day, in severe cases. The injections were given 
into the abdomen or buttocks. He thinks that the 
average dose should be determined by the severity of 
the disease, and not by the age of the child, and he 
vaccinated a child even as young as 1 month old. He 
feels sure that the length of the paroxysmal stage of 
the disease is diminished, and that the paroxysms are 
diminished in severity. 

Immunizing doses, to prevent the development of 
the disease in other children of the family, have been 
given in doses of 20 million bacilli, and the dose 
repeated four or more times, and the disease has been 
apparently prevented by such vaccination. More 
recently Hess® has made a careful study of the vaccine 
treatment of whooping-cough, and was disappointed 
in this treatment of the disease ; but he did find that in 
a certain percentage of cases immunizing doses pre- 
vented the development of the disease, although this 
prophylaxis was far less efficient than is typhoid vac- 

5. Sill, E. M.: The Vaccine Treatment of Whooping-Cough, Am. 
Jour. Dis. Child., May, 1913, p. 379. 

6. Hess, A. F.: The Use of a Series of Vaccines in the Prophylaxis 
and Treatment of an Epidemic of Pertussis, The Journal A. M. A., 
Sept. 19, 1914, p. 1007. 



134 TREATMENT OF PAROXYSMS 

cine in preventing typhoid fever. Positive conclusions, 
therefore, as to the value of vaccine treatment in 
whooping-cough cannot yet be made. 

The third indication, namely, to diminish the severity 
of the paroxysms, is of great importance. It has 
already been stated that the more quiet the child, the 
less frequent will be the paroxysms. Also, if the child 
lies down as soon as he begins to cough, he is less likely 
to vomit. An elastic abdominal belt seems to be of 
value in controlling the vomiting and the paroxysms 
of young infants especially. In some patients the 
paroxysms are so severe that chloroform inhalations 
have been given to prevent the intensity of the spasms. 
Also, it has been stated that inhalations of chloroform 
actually lengthen the time between the paroxysms and 
shorten the disease. Chloroform inhalations may act 
as a germicde. On the other hand, the frequent 
administration of chloroform, even in small doses, is 
known to injure both heart and kidneys. 

The most effective of all medicinal treatments, in 
the opinion of several authorities, is antipyrin and 
digitalis. A very good rule for the dosage of antipyrin 
is 0.05 gm. (about 1 grain) for every year of the 
child's age. This should be given three or four times 
a day, depending on the frequency of the paroxysms. 
The frequency should be diminished as the frequency 
of the paroxysms diminishes. Coincident with the 
antipyrin should be given digitalis in the form of the 
tincture, and in the dose proper for the child's age, 
and determined by its effect on the child's heart and 
pulse. The heart needs help, both from the strain of 
the disease and also as antipyrin might cause some 
weakening of the heart. The antipyrin acts by causing 
less irritability of the nervous system and relaxing 
muscle spasm. Even although the drug has disadvan- 
tages, its disadvantages are much less than the harm 
caused by the whooping-cough paroxysms. 



TREATMENT OF COMPLICATIONS 135 

The bromids have been frequently given and in large 
doses. They act by inhibiting the reflex activity of the 
nervous system and by more or less dulling the periph- 
eral nerves in the throat and upper air passages. 
Chloral has been used in order to depress the nervous 
irritability. Atropin or belladonna have been given in 
large doses, and their value must be in dulling the 
peripheral nerves in the irritated part of the body. 
Atropin is a stimulant, and cannot have any good 
effect in this disease, unless the dose is very large, and 
with such large doses atropin intoxication readily 
occurs, that is, the pulse becomes rapid, the throat dry, 
the face flushed, and there is likely to be cerebral 
excitation and perhaps dilated pupils. 

Antipyrin is best given to a child in solution, as 
follows : 

Gm. or c.c. 

I^ Antipyrinae 51 5 iss 

Aquae menthae piperitae. .. 100| flSiv 

M. et Sig: A teaspoonful, in water, three or four times a 
day. 

This dosage is for a child 5 years old. 

Various hydrotherapeutic measures are often of 
value, and the hot bath is always useful in quieting the 
patient and relieving internal congestions. 

The fourth indication, namely, to treat complications 
as they occur, is almost supererogation, as each com- 
plication calls for its proper treatment. However, 
under this heading the prevention of such complica- 
tions may be urged. Vomiting may be prevented by 
quiet, rest for a while after eating, by the abdominal 
belt and by proper food. Nutrition must be kept up 
at any cost, and, if necessary, the child given simple 
liquid nourishment every three hours. Not infre- 
quently cod-liver oil is well borne and is an oil nutri- 
ment of great value. Anemia must be prevented by 
iron. If it is seen that the heart is becoming strained, 
and the face and throat remain congested even after 
the paroxysm is over, showing that the right ventricle 



136 WHOOPING-COUGH 

is in trouble, digitalis should be given and such rest as 
would be given any damaged heart. This treatment 
also tends to prevent hemorrhages. Even if the child 
is weak and the circulation is weak, strychnin is inad- 
visable, as it stimulates the nervous system and causes 
or allows more paroxysms to occur. 

If the child has a history of enlarged glands or 
recurrent colds, or has inherited a tendency to tuber- 
culosis, or tuberculosis has been present in the child's 
family, its convalescence after whooping-cough should 
be prolonged, and country or seashore air should be 
urged where possible. Certainly, such a child should 
not be confined in school until his nutrition has become 
as good as before the infection with whooping-cough 
occurred. 



MUMPS 



This is a highly infectious disease, with a long period 
of incubation, from two to three weeks. There is 
more or less of it always present in most cities, and 
there are likely to be epidemics of it in certain seasons 
of the year, more particularly, perhaps, in the spring 
and fall. Children and youth, especially boys and 
young men, are the most susceptible to it. Infants and 
adults are not so likely to have it. Possibly adults are 
less likely to have it because they have been rendered 
immune by unrecognized mild attacks in childhood. 

While the typical localization of this infection is in 
one or both parotid glands, the submaxillary glands 
may be coincidently involved, or may be the only 
glands involved. As simple and harmless as this dis- 
ease generally is, it may cause very high temperature, 
sudden cardiac failure, and frequently in young boys 
and male adults a complication, or metastasis, of 
orchitis, which is always serious. In girls the mam- 
mary glands or the ovaries may show metastatic 
inflammation. 

The complication of inflammation of the sexual 
glands is frequently attributed to the patient's taking 
cold. While chilling may be a factor in causing such 
complications, young men especially who remain in 
the house or even in bed may develop this complica- 
tion of orchitis, and the danger of such a complication 
is greater after puberty than before. The peculiar 
interrelation of the parotid gland and the testicles or 
ovaries is biologically interesting, but has not been 
explained. Other complications are diarrheal attacks 
with bowel cramps, and in rare instances serious 
meningitis occurs. It is rare that more than one tes- 
ticle is affected. This is exceedingly fortunate, as this 



138 MUMPS 

testicle may be long hypertrophied and later atrophy 
and become permanently sexually insufficient. It is 
probable that the same history is true of an ovarian 
complication, and may be an undiagnosed cause of 
some forms of ovarian pain and dysmenorrhea. 

The parotid glands in this affection seem to show- 
no tendency to suppurate, but parotitis, whether the 
epidemic form or a complication of some other dis- 
ease, may cause serious cardiac depression. Even 
with high temperature in epidemic parotitis the pulse 
will often be found abnormally slow, at least for the 
height of the temperature. 

Any great amount of manipulation of the inflamed 
parotid gland in mumps should be condemned as tend- 
ing to cause absorption into the circulation of depres- 
sant toxins or secretions. This caution is not unique, 
but is parallel with the danger from too much manipu- 
lation of a hyper secreting thyroid gland, causing 
absorption into the blood of cardiac depressants. 

The prognosis v/hen meningitis is present is serious. 
Deafness has been caused, and even an optic neuritis 
has been stated to occur. Sudden death occasionally 
occurs without any assignable cause, except a sudden 
upright position after a patient has been in bed. Albu- 
minuria may be present with high temperature, and 
acute nephritis has occurred. Endocarditis is another 
rare complication. 

The white blood count in this disease is more or less 
characteristic, there being a lymphocytosis, although 
the whole number of leukocytes may vary, early in 
the disease being below normal. Barach^ states that 
there is a leukopenia due to a decrease in the poly- 
nuclear cells, both relatively and absolutely, all through 
the disease. On the other hand. Felling^ states that 
there is always a slight increase in the total number 
of leukocytes. Barach also states that the mononuclear 

1. Barach, J. H.: Morphology of the Blood in Epidemic Parotitis, 
Arch. Int. Med,, December, 1913, p. 751. 

2. Feiling, A.: Lancet, London, July 12, 1913. 



TRANSMISSION . OF MUMPS 139 

cells are relatively and absolutely increased. As the 
blood returns to normal the eosinophils, which have 
been almost absent, return in their usual numbers. 
This blood count is very distinct from the leukocytosis 
that is apt to be present if the gland is infected secon- 
darily and an abscess is liable to form, in which case 
there would be a polymorphleukocytosis. 

Contagium from this disease is probably pretty 
direct, that is, by close contact; but the contagium 
may be transmitted from the very early stages of the 
disease to perhaps some time after the disease is in 
abeyance. It has not been shown that animals are 
affected by the disease. 

A patient with the disease should generally be 
isolated, and the attack will often be milder if the 
patient remains in bed. Although the disease can be 
serious, it is generally so mild in children that it is 
sometimes a question whether other children of the 
same family should not be allowed to contract it, for 
the reason that one attack generally confers immunity 
for all time, and the disease is much more serious in 
adults, especially in young men, than in children. Of 
course, an infected child, even though very mildly 
sick, is immediately sent home from school. On the 
other hand, doubtless not a few children with very 
mild cases are unwittingly allowed to remain at school. 

The disease generally begins in one parotid gland 
and quickly goes to the other, although not infre- 
quently only one gland is affected. Occasionally the 
submaxillary or sublingual glands are the only 
ones attacked, and these cases may spread the mumps 
before the diagnosis is made. The inflammation in 
the first gland affected generally reaches its height in 
about four days, and the gland generally has returned 
to its normal size in from six to eight days. If the 
other gland is not quickly inflamed, but becomes 
inflamed later, the duration of the disease will be 
prolonged. The fever is generally mild, but it may be 



140 TREATMENT OF MUMPS 

very high, and in such instances there is always likely 
to be more or less cardiac depression. 

The same care of the child's surroundings in school 
should be given as in other contagious diseases to pre- 
vent the infection of others. The nurse or the mother 
should understand that infection is doubtless con- 
tained in the mucus and secretions of the mouth and 
throat; consequently infection will be given by close 
contact, as by kissing, by handkerchiefs, eating utensils, 
pencils, bedclothing, etc. 

TREATMENT 

The disease is so mild that it may not require any 
special treatment. Pain in the infected glands is 
rarely severe, and is modified by dry warmth or simple 
absorbent-cotton applications, and by any oily appli- 
cation, the latter to relax the tension of the skin over 
the swollen gland. For this purpose olive oil may 
be used, or petrolatum, or an ointment may be made 
with 10 per cent, methyl salicylate in petrolatum. It 
is inadvisable to use ice or cold applications to the 
parotid glands in mumps. 

The diet should be mild, the bowels kept free, and 
in simple cases medicinal treatment is not needed. If 
the fever is very high, one or two doses of antipyrin 
or acetanilid may be given, with the knowledge that 
cardiac depression readily occurs in this disease. Hot 
drinks, as hot lemonade or hot tea, with a little alcohol 
in some form for its physiologic action in dilating the 
peripheral blood-vessels and promoting perspiration, is 
a satisfactory method of reducing the temperature. 
Tepid sponging may be of benefit, and hot sponging 
should be given the patient daily if he is too ill for a 
hot bath. 

If a testicle is affected, the lesion is generally an 
orchitis, or it may be an epididymitis. Ice and cold 
applications are inadvisable in this metastasis from 
mumps. Warm, moist applications often relieve 



TREATMENT OF COMPLICATIONS 141 

pain; but if the testicles are kept elevated and sur- 
rounded by absorbent cotton, and if perhaps some oil 
or fat, such as petrolatum, is applied, the inflammation 
will probably go away as rapidly as by any other treat- 
ment. Strapping is inadvisable in this complication. 
Any massage, or the rubbing in of any ointment or 
other preparation in this kind of orchitis, or to the 
parotid glands, is inadvisable in mumps. Ichthyol 
applications in from 10 to 20 per cent, strength, either 
in petrolatum or in olive oil, or glycerin and water, 
have been largely used locally in this inflammation. 
Lead and opium wash has been frequently used; but 
the less this inflamed gland is manipulated, the better. 

If the mammary gland becomes metastatically 
inflamed, the treatment is about the same as that for 
the parotid. If it is decided that the ovary is inflamed, 
but little can be done, except absolute rest and the 
administration of a sedative if there is pain. If there 
is much pain from any of these inflamed glands, mor- 
phin or codein may be advisable if it seems unwise to 
give a coal-tar analgesic. 



DIPHTHERIA 



This disease was long thought to be due to filth, 
because, like all sore throats, etc., it seemed to be 
more prevalent in dirty, damp, and crowded places. 
This is true only because it is not so readily eradicated 
from such surroundings, more cases are not discov- 
ered, and more carriers are found in such localities. 
Many sore throats w^ere termed diphtheritic when they 
were septic, or cases of tonsillitis with membrane, or 
were really scarlatinal cases. Also, membranous croup 
was long held to be distinct from diphtheria. With 
the discovery of the contagium of diphtheria, the 
Klebs-Loeffler bacillus, it is now conceded not only that 
the discovery of this germ in the secretions of the 
throat, nose, or other parts of the body proves that 
diphtheria is present, but also that its absence is proof 
that the disease is not present, provided that the swab 
is properly taken and the culture made by an expert. 
Also, it has now long been proved that membranous 
croup is laryngeal diphtheria. 

This throat inflammation, now termed diphtheria, 
has been known for centuries, having first appeared in 
the East and later in Europe, occurring mostly in 
epidemics. Now it is endemic in most civilized cities, 
although small epidemics, localized in certain build- 
ings, public institutions, tenements, or schoolhouses, 
frequently occur. A carrier of this disease may com- 
municate it to persons so widely separated as to make 
the occurrence of the disease almost unexplainable by 
any epidemic theory. While nearly all mankind is 
susceptible to small-pox, and a large majority to scar- 
let fever, many persons seem naturally immune to diph- 
theria. Also, a closer contact is apparently needed 
with an infected individual than in these other diseases. 



TRANSMISSION OF DIPHTHERIA 143 

As one attack of diphtheria does not cause immunity 
from the disease for any great length of time, and as 
preventive measures do not protect for any great 
length of time, it is difficult to eradicate this disease. 
Small-pox could doubtless be prevented entirely in 
any country in which every individual was vaccinated 
at least two or three times during his life. Such pre- 
vention of diphtheria cannot be expected; but a more 
rigid quarantine of diphtheria patients, and a greater 
effort made to discover carriers and isolate and treat 
them will render diphtheria less and less frequent. 

This disease has always had a large percentage of 
deaths; but the death rate since the introduction of 
antitoxin has been constantly on the decrease, and with 
a better understanding of the proper dosage of anti- 
toxin, and with the effort made to diagnose the disease 
early, the death rate will be more rapidly decreased. 
Our best sanitarians believe that for every case of 
diphtheria recognized, at least one sore throat that car- 
ries the Klebs-Loeffler bacillus escapes ; in other words, 
there is an equal number of missed mild cases. 

It has been shown that patients with diphtheria 
when coughing, or even talking, will throw diphtheria 
bacilli into the air, and if such are deposited on cul- 
ture plates not far from the patient, diphtheria bacilli 
will grow. It has also been shown that the Klebs- 
Loeffler bacillus lives longer where it is cold and damp 
than where it is dry and hot. The disease is more 
prevalent in cold weather, and the germ does not die 
so readily and become non-infectious in cold, damp 
rooms. Besides every care to prevent the spread of 
infection from the patient, the bedroom should be kept 
warmer in cold weather than with most diseases, not 
only because of the foregoing fact, but also because the 
toxins of diphtheria bacilli are depressing, and the 
patient's temperature is often too low. 

It has been shown that the normal hydrochloric 
acid in the stomach inhibits or kills the diphtheria 
bacilli; therefore it is exceedingly rare to find these 



144 CARRIERS 

germs in the intestines, and very rare to find diph- 
theritic membrane in the stomach. 

In the majority of cases the tonsils, one or both, are 
the parts affected in diphtheria, and with the present 
methods of treatment, in a large portion of these cases 
the membrane will be limited to these regions. The 
soft palate is next most frequently attacked, the 
pharynx next, and nasal diphtheria, with proper care 
taken, is not very frequent. Laryngeal diphtheria is 
not a frequent complication to tonsillar diphtheria; 
it generally begins as the original point of attack. 

CARRIERS 

These may be convalescents from diphtheria, or may 
be those who have had contact with diphtheritic 
patients who may or may not later develop the dis- 
ease, or the term may be perhaps more properly limited 
to those who carry the germ for months. Diphtheria 
germs may live a long time on books or other sub- 
stances, handled, coughed, sneezed or expectorated 
on by a diphtheria patient, and may infect persons 
coming in close contact with such infected material. 
This method of infection may not be very frequent. 
Animals may carry the infection. It is doubtless a 
good axiom to believe that a tonsillitis with exudate 
is diphtheria until it is proved not to contain the 
Klebs-Loeffler bacillus. Such a patient should be 
more or less rigidly isolated, as streptococcic infection 
is, if anything, more readily communicated than is 
a diphtheria infection. Therefore, there can be no 
excuse for not isolating a sore throat with exudate 
or membrane as soon as such a case is discovered. 

The subject of carriers and the length of time which 
the Klebs-LoefBer bacillus may remain in the throat 
m^ay be studied by reference to the article of Henry 
Albert^ and that of Henry Page.'^ Both of these 

1. Albert, Henry: The Treatment of Diphtheria Carriers, The 
Journal A. M. A., Sept. 27, 1913, p. 1027. 

2. Page, Henry: Diphtheria Bacillus Carriers, Arch. Int. Med., 
January, 1911, p. 16. 



CARRIERS OF DIPHTHERIA 145 

papers give many references and quote many authori- 
ties. Albert quotes Ledingham as stating that 50 
per cent, of persons affected with diphtheria have lost 
the bacilli by the time the local membrane has dis- 
appeared. The average length of time that the bacilli 
will persist in a throat is thirty days, as shown by a 
very careful clinical and bacteriologic study of a 
diphtheria epidemic by Jessie W. Fisher.^ She found 
that these germs could persist for more than 100 days, 
and in one instance 111 days. Not every bacillus car- 
rier shows virulent germs, but in a large proportion 
of such bacilli carriers the germs are virulent; there- 
fore a bacillus carrier should always be considered able 
to infect others. Even if such bacilli are proved not to 
be fatal to guinea-pigs, they might be able to infect a 
human being. Dr. Fisher also discovered that a sewer 
could become contaminated with diphtheria bacilli, 
that rats living or eating refuse in this sewer could 
become infected, and that cats catching or eating the 
rats could become carriers. Cats associating with a 
diphtheritic patient may frequently become carriers. 

Klein* thought that cows could become infected and 
could cause infection of milk, which, unboiled, could 
infect an individual. Infected milk certainly can cause 
streptococic throats, and it would seem likely could 
cause diphtheria. Probably a pet dog could carry the 
disease as readily as a cat. Therefore the rule and 
regulation of every physician should be that cats and 
dogs should be excluded from the sickroom of a patient 
with any kind of sore throat ; and if other cases occur 
in a family in which quarantine is properly carried out, 
not only should the throats of all persons be examined, 
but also the cat or dog should be suspected. 

The location of the Klebs-Loeffler bacillus in car- 
riers who are convalescing is probably most frequently 

3. Fisher, Jessie W. : A Diphtheria Epidemic, The Journal A. M. A., 
Feb. 6, 1909, p. 439. 

4. Klein: Local Gov. Board Rep., London. 1899, xxix. 



146 TREATMENT OF CARRIERS 

in the throat, though the bacillus may be found in the 
nose. In those who carry these germs long they are 
more likely to be found in the nose. Therefore, 
swabs should be taken of both regions. It is quite 
probable that a surface swab from a tonsil may be 
negative while a culture obtained from probing into 
crypts of the tonsils or in the region back of the tonsil 
might show the presence of the germ. It is culpable 
neglect to fail to examine a patient thoroughly to ascer- 
tain if he is free from the Klebs-Loeffler bacillus. 

The boards of health vary as to the number of nega- 
tive cultures that will release a patient from quaran- 
tine. The safest number is perhaps four negative cul- 
tures, two from the throat and tonsils, one from crypts 
or back of the tonsil, and one from the nose, taken on 
alternate days, at a considerable interval from the use 
of any antiseptic washes, gargles or sprays. This 
would seem to prove that a patient was free from the 
Klebs-Loeffler bacillus. In instances in which epidem- 
ics of diphtheria have occurred and cultures have been 
taken from the throats of a large number of well per- 
sons in the same institution, it has almost invariably 
been shown that a certain small percentage of such 
persons have acquired the germ and are carrying it 
without becoming actively infected. 

TREATMENT OF CARRIERS 

Various methods of ridding a carrier of the diph- 
theria germ have been tried. Local measures vary, 
and may comprise painting the suspected regions with 
tincture of iodin or with Lugol's solution, with silver 
solutions, phenol solutions, or the use of various gar- 
gles, hydrogen peroxid solutions, etc., and the nasal 
inhalation of various thymol or iodin inhalants or 
sprays. There is no question that whatever else is 
done, some local antiseptic should be applied. Diph- 
theria antitoxin injection has not been very succes- 
ful. Local applications in the mouth, throat or nose 
of antidiphtheritic serum have not been proved to be 



TREATMENT OF CARRIERS 147 

very successful. Vaccinations with dead diphtheria 
bacilH have been only partially successful. These 
various methods are described by Albert.^ He believes 
that a local application to suspicious crypts of the 
tonsils of a "5 per cent, solution of silver nitrate 
will destroy all bacteria with which it comes in con- 
tact." A thorough application of a 10 per cent, solu- 
tion of silver nitrate he finds will cause some destruc- 
tion of the epithelium of a crypt and a fibroblastic 
proliferation with ultimate obliteration of the lumen, 
which is of course the object desired. 

The most successful treatment of diphtheria car- 
riers seems to be that of spraying the nose and throat 
with pure cultures of Staphylococcus pyogenes aureus. 
According to the reports, this spray is apparently 
harmless to the individual. This method was first 
used by Schijzitz, in 1909. Although it is not always 
efficient, in some instances it has removed the Klebs- 
Loeffler bacillus and prevented its growth so that cul- 
tures were negative to it in a week or less. It has 
not proved very successful in nasal cases. Discussions 
of this treatment are given by Catlin, Scott and Day,^ 
Lorenz and Ravenel,^ and RoUeston."^ On the other 
hand, Womer,^ after using this staphylococcus spray 
in forty-two cases of diphtheria carriers, comes to the 
conclusion that although it is harmless, it does not 
appreciably lessen the period of quarantine. This 
leaves the value of this treatment still subject to posi- 
tive proof. It may certainly be tried. 

Womer states that "apparently most of the carriers 
do not spread the disease after sixty days from the 
day the disease begins." The word "most" leaves this 

5. Catlin, S. R.; Scott, L. O., and Day, D. W.: Successful Use of 
the Staphylococcus Spray on Diphtheria Carriers, The Journal A. M. A., 
Oct. 28, 1911, p. 1452. 

6. Lorenz, W. F., and Ravenel, M. P.: The Treatment of Diphtheria 
Carriers by Overriding with Staphylococcus Aureus, The Journal 
A. M. A., Aug. 31, 1912, p. 690. 

7. Rolleston: Brit. Jour. Child. Dis., July, 1913, 

8. Womer, W. A. : Results of Staphylococcus Spray Treatment in 
Forty-Two Cases of Diphtheria Carriers, The Journal A. M. A., Dec. 
27, 1913, p. 2293. 



148 IMMUNITY IN DIPHTHERIA 

assertion doubtful as far as general practice is con- 
cerned. Any one person who carries the disease may- 
be one that could infect others. 

Wood^ thinks that in one or two instances, in diph- 
theria, spraying the affected areas with live lactic acid 
bacilli hastened the disappearance of the diphtheritic 
germ. Antiseptics should not immediately be used in 
the throat after such spraying, as he thinks it is the 
live bacilli that act perniciously on the diphtheria bacil- 
lus. This suggestion is worthy of further investigation. 

Miller^^ recommends that diphtheria carriers have 
their throats sprayed with warm f ormaldehyd solutions 
every three or four hours during the daytime. The 
strength which he recommends to begin with is 0.25 
or 0.5 per cent, in water of a 40 per cent, formaldehyd 
solution. [The official Liquor Formaldehydi is a 37 
per cent, solution.] This solution may be increased in 
strength to 1 per cent, if deemed advisable. He found 
that in from three to six days the diphtheria bacilli 
disappear from the throats of carriers thus treated. 
He urges that the solution be prepared fresh each day. 
He did not find that the kidneys were irritated by such 
treatment. 

IMMUNITY 

While it has been long known that infants and many 
adults seem not to be susceptible to diphtheria, it has 
only lately been shown that probably a large propor- 
tion of adults, stated at 90 per cent., perhaps 50 per 
cent, of children, and perhaps 80 per cent, of new- 
born infants have diphtheria antitoxin in their blood 
and are not likely to become ill with diphtheria. It 
should be noted, however, that individuals protected 
against self-infection may be carriers of diphtheria 
bacilli which can infect others. How many of these 
immune adults or older children have been always 
immune, and how many have acquired immunity by 

9. Wood, Harold B.: Lactic-Acid Bacillus Spray for Diphtheria, The 
Journal A. M. A., Aug. 9, 1913, p. 392. 

10. Miller: Med. Rec, New York, July 25, 1914. 



SCHICK TEST IN DIPHTHERIA 149 

contact with diphtheria germs, is not known. Nurses 
and physicians who frequently care for diphtheria 
patients have been shown to have antitoxin in their 
blood, though they may never have had the disease. 
A skin test has been devised, known as the Schick 
reaction, to determine whether or not an individual 
is protected against diphtheria, that is, whether he has 
diphtheria antitoxin in his blood. The reaction seems 
very positive, and distinctly shows whether an indi- 
vidual is artificially protected or has natural antitoxin 
against this disease. The test is made with a dilute 
diphtheria toxin of such strength that 0.1 c.c. contains 
one-fiftieth of the minimum fatal dose for a guinea- 
pig. This amount, namely, 0.1 c.c, is injected into the 
layers of the skin, perhaps best on the inner surface 
of the arm. A positive reaction should appear in from 
twenty-four to forty-eight hours, and is evidenced by a 
slight swelling and localized redness, a reddened papule 
v/hich remains from seven to ten days. When this 
papule disappears, the skin over it may desquamate 
slightly, and pigmentation may remain for days and 
even weeks. Park states that the injection is best given 
with a small hypodermic syringe with a platinum point 
needle, that the injection must be into the skin and not 
subcutaneously, and that immediately after the injec- 
tion there should be a raised whitish spot, which in 
twenty-four hours becomes bluish, with a slight edema. 
Schick's interpretation of the positive reaction, as just 
described, is that the patient has no antitoxin in his 
blood, or at least less than 1/30 unit of antitoxin in 
1 c.c. of blood. He declares that all persons so react- 
ing are susceptible to diphtheria, and Park agrees with 
him. Park,^^ in his summary on immunity in diph- 
theria, states that according to Hahn the interval 
between the injection of vaccine and the development 
of antitoxin is not less than three weeks, while other 



11. Park, W. H.; Zingher, A., and Serota, M. H. : Active Immuniza- 
tion in Diphtheria and Treatment by Toxin-Antitoxin, The Journal 
A. M. A., Sept. 5, 1914, p. 859. 



150 TOXIN-ANTITOXIN INJECTIONS 

investigators think that it may be eight days. Persons 
who have a natural antitoxin show an earher increased 
antitoxin production. Von Behring considers that 0.01 
unit of antitoxin per 1 c.c. of blood is sufficient to pro- 
tect a healthy individual, and much less may protect 
against diphtheria. 

Park states that last year in the Willard Parker 
Hospital one-fourth of the inmates were diphtheria 
carriers, and he found that "active immunization pro- 
duced a very decided increase of antitoxin in a rela- 
tively short time in all persons who had natural anti- 
toxin." Park found that 400 out of 700 scarlet fever 
patients showed natural immunity by the Schick reac- 
tion; that is, 57 per cent, were immune. He comes 
to the conclusion that persons positively exposed to 
diphtheria should be passively immunized even if the 
toxin-antitoxin injections have been given ; but he urges 
that the Schick test will prevent the necessity of 
immunizing about two-thirds of such exposed persons. 
In other words, a person suspected of being exposeH to 
diphtheria should receive the Schick test. If this is 
positive, showing that he is susceptible, he m^ay be 
passively immunized with antitoxin. If he has not 
been immediately, but is likely to be, exposed and 
should be protected,, he may be actively immunized 
with a vaccine. Such active immunization Park 
believes will last only from one to two years; hence 
general protection of large numbers of individuals 
against this disease cannot yet be urged. Park quotes 
Bauer as finding that the persistence of the bacilli in 
carriers is not shortened by active immunization. 

The toxin-antitoxin injections used by Park are 
described in his article. The von Behring vaccine^^ 
"consists of a mixture of strong diphtheria toxin and 
antitoxin in such proportions that the toxin is just 
neutralized or is in very slight excess when tested on 

12. Veeder, B. S.: Active Immunization Against Diphtheria by Means 
of von Behring's Vaccine, and the Diphtheria Toxin Skin Reactions, 
Am. Jour. Dis. Child., August, 1914, p. 154. 



ACTIVE IMMUNIZATION 151 

a guinea-pig." These injections are given intracutane- 
ously, and immunity occurs in about ten days. Indi- 
viduals with natural antitoxin in the blood may be more 
susceptible to reaction from this toxin-antitoxin vac- 
cine than those without such antitoxin, and individuals 
who have antitoxin in their blood from previous infec- 
tion may show a hyper sensitiveness to the injection. 

As just stated, patients so actively immunized are 
apparently protected for at least one year, while a 
patient who receives an immunizing dose of antitoxin 
is protected for perhaps not more than ten days. How- 
ever, this antitoxin immunization is rapid and will gen- 
erally protect a patient from one exposure to this germ. 

Veeder^^ carefully reviews the literature on the sub- 
ject of this vaccination, and finds that there is a 
marked variability of reaction to such injections, and 
quotes Kissling as believing that the injection should 
be made into the back instead of the arm, and that 
more dilute injections should be given, and if a milder 
one causes considerable reaction, a stronger one should 
not be used. If the milder one causes no reaction, a 
strong injection may be given. A "negative phase" 
has not been discovered ; a patient who has been vac- 
cinated with toxin-antitoxin, on subsequent exposure 
to diphtheria may receive antitoxin without showing 
hypersensitiveness. It has been shown that diphtheria 
carriers have more antitoxin in their blood than is 
found in the blood of patients who have just recovered 
from an attack of the disease.^^ 

Von Behring^* believed that the dose of toxin-anti- 
toxin injected can be gaged accurately according to the 
weight of the individual. This he has worked out on 
animals. 

The future advantage of this kind of protection 
against diphtheria lies in the fact that a foreign serum 
like horse serum need not be used in a patient who is 

13. Otto: Deutsch. med. Wchnschr., March 12, 1914, p. 542. 

14. Zangemeister and von Behring, Deutsch. med. Wchnschr., May 
22, 1913. 



152 IMMUNIZATION WITH ANTITOXIN 

a hay fever or asthma subject. It is quite probable 
that it would be unwise, at least at the present time, to 
use this toxin-antitoxin in diseased or damaged indi- 
viduals, as those with a weak or diseased heart. At 
least, this precaution is suggested. It may later be 
shown that a dose so small as to give practically no 
reaction may still be sufficient to immunize. It is 
reported by Schreiber^^ that in vaccination by von 
Behring's method of 700 schoolchildren and 300 chil- 
dren in a hospital, there have been no untoward effects. 

Immunizing doses of antitoxin to persons who have 
been exposed to diphtheria, given early, are generally 
successful in preventing the development of the dis- 
ease. The immunizing dose for a child should prob- 
ably be at least 1,000 units. Doubtless adults should 
receive larger doses. In the epidemic reported by Dr. 
Fisher, of the large number of immunizing doses given, 
but one person, a nurse, subsequently developed an 
attack of diphtheria during the period of observation. 
She had a mild attack at the end of two weeks. Dr. 
Fisher believes that two weeks is the limit of protection 
from a dose of immunizing antitoxin. 

In the epidemic which occurred at Johns Hopkins 
Hospital, in 1911, Dr. Ford^« reports that of 300 
prophylactic doses of antitoxin administered, in most 
cases the reaction was limited to a slight urticaria. In 
a few instances there was some local edema, tender- 
ness, and elevation of temperature. In five cases 
there were characteristic symptoms of serum disease, 
and in one of these cases there was typical anaphylac- 
tic shock. The patient who developed shock had 
previously received antitoxin, and had a history of 
asthma. It would have been interesting to note if all 
the other individuals who received the antitoxin had 
never been subject to asthma or hay fever: whether 
this shocked individual was the only one who had a his- 
tory of asthma. 

15. Schreiber: Therap. d. Gegenw., 1914, Iv, No. 3. 

16. Johns Hopkins Hosp. Bull., October, 1911, p. 357. 



PROPHYLAXIS IN SCHOOLS 153 

PROPHYLAXIS IN SCHOOLS 

When it is reported to a school board and to a 
board of health that a schoolchild is sick with diph- 
theria, it should first be remembered that with every 
discovered case probably one other missed case occurs. 
Of course the sick child is isolated. The other chil- 
dren of this family should have cultures taken from 
their throats to determine whether or not the Klebs- 
Loeffler bacillus is present; but without waiting for 
the results of this investigation, each should receive 
an immunizing dose of 1,000 units of diphtheria anti- 
toxin, unless their history shows that they are asth- 
matics or sufferers from hay fever. As it takes from 
twenty-four to forty-eight hours for the Schick test 
to develop, it seems unwise, in the case of children 
who have been in close contact with the infected 
patient, to postpone the administration of the anti- 
toxin, until a Schick test shows whether or not they 
are already protected. 

These children should, of course, all be forbidden to 
attend school, and should be isolated as far as possible 
from other children. If the infected child comes from 
a tenement house where there are many children, the 
other children in this tenement should also be 
excluded from school until it is shown that their 
throats contain no Klebs-Loeffiler bacilli. 

If several cases of diphtheria occur one after the 
other or more or less rapidly in a schoolroom, or in 
different parts of a school, all of the children who are 
closely associated, either at their desks, or in classes, 
or as chums, should have their throats tested to ascer- 
tain who are the bacillus carriers. Instruction should 
be carefully given to the parents of the children who 
are well but have been positively exposed to diph- 
theria, to prevent their playing with unexposed chil- 
dren, thus possibly spreading the disease before it is 
ascertained that they are free from diphtheria bacilli. 

General disinfection, by fumigation, of a school- 
room which has contained several diphtheria cases is 



154 PROPHYLAXIS IN SCHOOLS 

considered by most advanced sanitary experts as 
unnecessary and of little value. If swabs from the 
throats of all the children in this room are taken and 
the room then closed for twenty-four hours and thor- 
oughly sprayed and washed with germicidal solutions, 
the other children who do not belong to the infected 
families may return to the schoolroom as soon as the 
board of health has determined which throats carry 
the diphtheria bacilli. It does not seem scientifically 
wise or economically sensible to close a schoolroom or 
a school building for an indefinite period when the 
foregoing measures will be effective in stamping out 
the disease. 

A child whose throat and nose is found to be free 
from the Klebs-Loeffler bacillus may immediately 
return to school, provided he is not allowed to come 
in contact again with a new case of diphtheria. A 
child whose throat does contain the diphtheria bacilli, 
though he is not ill, should be isolated and treated with 
antitoxin if he has been recently exposed, or with 
the method suggested above for treating carriers, if 
he has apparently not been recently exposed. Under 
any circumstances, such a child should not be allowed 
in school. 

The throats of the teachers and instructors in the 
schools in which diphtheria has occurred should also 
be tested. Other members of the family in which 
there is a patient with diphtheria should be examined 
and if they are found free from the bacilli and do not 
come in contact with the patient, they can with pro- 
priety live at home and attend to their regular occu- 
pation. This is on the supposition that the infected 
patient is properly quarantined (which means the 
kind of quarantine advised by the board of health), 
is attended by a physician, and is cared for by a 
nurse, or by one person who remains isolated with the 
patient, at least as far as close contact with others is 
concerned. There is no reason why the nurse should 



TREATMENT OF DIPHTHERIA 155 

not change her clothing and go out for fresh air daily. 
She should not go into stores or ride in cars where 
she might give the disease to others, as she is likely to 
carry the germ in her own throat, though being herself 
immune. 

TREATMENT 

A. Isolation. — It should again be urged that a throat 
with spots or membrane should be considered as likely 
to be diphtheritic until a culture has proved it not to be. 
Such a patient should be isolated in the best room avail- 
able, looking toward the possibility of the disease being 
diphtheria and a nurse being required. Other children 
of the family must be excluded from contact with 
this patient. If the case is clinically one of follicular 
tonsillitis, the physician may wait for a positive test 
before giving antitoxin. If, however, the case is 
clinically diphtheria, antitoxin should be given with- 
out a report being waited for, provided there is noth- 
ing in the history of the patient to show that there will 
be any hypersusceptibility to horse serum. If the dis- 
ease is diphtheria, and the patient is in a tenement 
where it is impossible to carry out isolation, he should 
be removed to a contagious disease hospital, if the 
city has one. Whether it is follicular tonsillitis, or 
other streptococcic infection, or diphtheria proper, 
gargles and local cleanliness of the throat should be 
immediately inaugurated, and when this is properly 
carried out, the danger of infection of others is 
reduced to a minimum. 

It is hardly necessary in this day, in which the 
advisability of sunlight, a large room, an adjacent 
bathroom, the absence of all unnecessary draperies, 
furnishings, rugs, etc., for a proper isolation room are 
so well understood, to describe the needs in detail. 
Instruction should be given the family in the minor 
details of the prevention of infection of others. A 
properly trained nurse well understands the necessity 
for burning wooden tongue depressors, wooden swabs, 



156 GENERAL CARE IN DIPHTHERIA 

the gauze and cotton used around the patient's nose 
and mouth, and washcloths; the use of liquid soap; 
simple but effective cleanliness of the patient's face, 
hands, and body; boiling of all eating and drinking 
utensils; disinfecting the toothbrush with non-poison- 
ous germicides; allowing the bed clothing and bed 
garments to stand in germicidal solutions before being 
sent to the wash ; frequent washing of her own hands 
in germicidal solutions; and gargling her own throat 
with peroxid hydrogen solutions. These are all sub- 
jects of general knowledge by physicians and nurses. 

B. General Care of Patient. — High fever is not 
frequent in diphtheria, unless the case has been 
neglected. Consequently, the patient should receive, 
almost from the beginning, plenty of nutritious food. 
The exact diet, of course, depends on the age of the 
patient. The frequency with which the nutriment is 
given depends on the amount that is taken; if the 
nourishment is liquid and in small amount, it should 
be given every three hours. The food should repre- 
sent all the elements that the patient needs for nutri- 
tion, namely, a considerable amount of protein, a 
goodly amount of starch, sugar, iron, salt and fruit 
salts, and plenty of water. Milk, oatmeal gruel, eggs, 
meat juice well salted, toast, butter, and the whole, 
or the juice, of one or two oranges, would represent 
the food needed. With or without meat, it is well 
to give a diphtheria patient iron, and no preparation 
is better than the tincture of iron chlorid in 5-drop 
doses, three times a day, given in fresh lemonade or 
orangeade, after nourishment. 

However well the gastric juice inhibits the growth 
of the bacteria, it is always wise for a patient to gar- 
gle, or be sprayed, before taking food, so that the 
mouth and throat will be as clean as possible. 

The bowels should be moved daily by some simple 
laxative, if they do not move without such help. 



ANTITOXIN TREATMENT 157 

While a diphtheria patient should have plenty of 
fresh air and all the sunlight possible, he should be 
kept warm. He should not be allowed to become 
chilled, as the toxins of this disease cause depression 
and the patient's temperature may be quite low, and 
the hands and feet easily become cold. Even if the 
temperature is high, the bathing should be by warm 
sponge bath. 

C. Antitoxin. — The Revision Committee of the 
Pharmacopeia will probably decide that the average 
dose of diphtheria antitoxin should be stated in the 
next Pharmacopeia as 10,000 units. Recent investiga- 
tions by Schick^^ show that the dose of antitoxin advis- 
able for ordinary cases of diphtheria can be based on 
the weight of the individual. Schick finds that 100 
units of antitoxin per kilogram of weight is sufficient 
to combat the toxin in diphtheria in all ordinary cases, 
and in severe cases 500 units per kilogram is more than 
sufficient. In other words, enormous doses of anti- 
toxin are not needed, which has long been the belief of 
Park of New York. This is especially true if the anti- 
toxin is given early. A kilogram equals 2 1/5 pounds 
avoirdupois, and a child weighing 45 pounds, in an 
ordinary case of diphtheria, should be given 2,000 
units of antitoxin; while if the case is severe, or in 
nasopharyngeal or laryngeal types, 10,000 units would 
be all sufficient. By the the same method of decision 
as to the dose, an adult of about 130 pounds should 
receive 6,000 units in a mild case, and 30,000 units if 
the diphtheria is of malignant type, or has affected 
parts where the danger of absorption is greater. 

It seems quite probable that if such doses could be 
administered on the first day of the infection with the 
Klebs-Loeffler bacillus, no more antitoxin will be 



17. Schick, B. ; Kassowitz, K., and Busacchi, P.: Experimentelle Diph- 
theric Serum-Therapie beim Menschen, Ztschr. f, d, ges. exper. Med,, 
1914, iv, 83. The Proper Dosage of Diphtheria Antitoxin, editorial, 
The Journal A. M. A., Dec. 12, 1914, p. 2134. 



158 RASH AFTER ANTITOXIN 

needed in such cases, and that death from this disease 
will be reduced to a minimum. It may be wise to give 
a young child a smaller dose, but it has not been 
shown, with the concentration of the serums now 
offered, that locally any harm is done by this injection, 
or that systemically (except in patients who have 
received antitoxin in longer or shorter time before, 
or in patients who are asthmatics or hay fever sub- 
jects, or are particularly susceptible to emanations 
from horses), antitoxin ever does any harm. A slight 
rash will occur in about half the cases in which anti- 
toxin is used, but such simple eruptions are harm- 
less. The rash may be scarlatiniform in type, or 
papular, or urticarial. It may occur within a few hours 
after the injection, or may not occur for some days. 
If it is in large amount, there may be increased tem- 
perature. Mild albuminuria is apparently no more 
liable to occur from the antitoxin injection than it is 
from the diphtheria. 

The subject of antitoxin injection and dosage has 
been ably considered by Dr. Woody^^ and by the physi- 
cians who discussed his paper. Woody advises that 
when both tonsils are covered with exudate of more 
than one day's duration, the smallest dose of anti- 
toxin should be 30,000 units. If both tonsils and the 
soft palate show membrane, and especially if the nose 
is involved, and the history shows a duration of 
three days or more, he would give 150,000 units as the 
smallest amount. When the nose alone is affected, he 
believes 20,000 units should be the dose; and in 
laryngeal diphtheria 30,000 units as the smallest dose 
is advised. If the case has been a neglected one and 
there are serious symptoms of toxemia, and especially 
in nasopharyngeal cases, in which the absorption of 
toxins is so rapid, he recommends the administration 
of from 50,000 to 150,000 units. While this dosage 
seems large, we should note the conclusions offered by 

18. Woody, S. S.: The Use of Antitoxin in Diphtheria, The Journal 
A. M. A., Sept. 5, 1914, p. 861. 



DOSAGE OF ANTITOXIN 159 

Woody after his extensive tabulated experience, 
namely, that with these large doses there is more rapid 
local cure and quicker improvement in the patient's 
general condition, a permanence of the cure, an avoid- 
ance of complications, a reduction of mortality, and 
withal, such dosage is apparently harmless. 

Dr. Park of New York, in discussing Woody's 
paper, advises nearly as large doses, namely, 5,000 
units in mild cases, 10,000 in severe, and 20,000 in 
malignant cases. In toxic cases in which the danger 
is serious and imminent, he would use the antitoxin 
intravenously, stating that "10,000 units intravenously 
is worth 100,000 units subcutaneously." He states his 
belief that "40,000 units will save any patient that 
1,000,000 will." 

In a more detailed discussion of diphtheria, Woody^^ 
brings out some points which we should continually 
bear in mind. He says: 1. "Diphtheria is essentially 
a local disease whose harmful effects are produced by 
certain toxic substances elaborated by the diphtheria 
bacillus." 

2. "The toxin of diphtheria readily reaches all por- 
tions of the body by means of the lymphatic circula- 
tion." This toxin shows a tendency to attack the 
kidneys, the nervous system, and the heart. The 
action of this toxin is inhibited only by the forma- 
tion of antitoxin in the body, or the introduction of 
antitoxin into the body. 

3. He classifies untoward symptoms following the 
use of diphtheria antitoxin as : (a) Those that occur 
in eight or ten days after the first injection with 
symptoms of fever, rash, joint pains, and at times 
slight albuminuria and edema. In Woody's experience 
this form of serum sickness occurs in 30 per cent, of 
the cases of antitoxin injection, (b) A similar reac- 
tion which may occur after a second dose of anti- 
toxin, provided the source of the antitoxin is the 

19. Woody, S. S.: Pennsylvania Med. Jour., February, 1914, p. 339. 



160 CARE OF THE THROAT 

same (that is, the same animal has been used), and 
which will come on more rapidly and be more intense 
and last a shorter time, (c) Anaphylactic shock or 
collapse, which he has elsewhere stated to be rare, 
which may occur after a second injection, and occa- 
sionally after the first one. 

Smith^^ and Park^^ have shown that when antitoxin 
is given subcutaneously, it takes from three to four 
days before the maximum amount of antitoxin is cir- 
culating in the blood. If the antitoxin is given intra- 
muscularly this period is shortened. From these find- 
ings, therefore, the conclusion should be made that 
if the case is urgent and the toxemia serious, anti- 
toxin should be administered intravenously; if the 
case is severe and the diagnosis has not been made 
early, antitoxin should be given intramuscularly; in 
ordinary or mild cases, and on the first day or two of 
the disease, it may be administered subcutaneously. 

D. Care of the Throat. — It would be just as sensi- 
ble to perform a major operation with the most per- 
fect technic and yet take no means whatever of pre- 
venting infection, as it is to administer antitoxin in 
proper dose in diphtheria and then to take no proper 
care of the throat. It should be remembered that 
diphtheria is primarily a local disease, that the anti- 
toxin combats only the toxins of the Klebs-Loeffler 
bacillus, that other germs are always found in diph- 
theritic throat, and that local putrefaction and septic 
infection readily occur if the throat and nose are not 
properly treated. While the antitoxin is hastening 
the throwing off of the membrane or inhibiting its fur- 
ther formation, the surface of this membrane mxust be 
washed off or cleansed gently, but frequently. All 
odor and all danger of secondary infection are removed 
by proper treatment of the part affected. Although 
germicdes cannot kill the germs deep in the mucous 
m.embrane, or those that are protected by an overlying 

20. Smith: Jour. Hyg., 1907, vii, 205. 

21. Park: Boston Med. and Surg. Jour., 1913, clxxiii, 73. 



GARGLES AND THROAT WASHES 161 

exudate, a certain large portion of the surface bac- 
teria are surely killed by as simple a gargle as hydro- 
gen peroxid solution. More active and more irritant 
germicidal gargles or germicides that are sources of 
danger when swallowed, are entirely unnecessary in 
diphtheria. 

If the child is old enough to gargle or swash the 
tonsils, this is the best method of cleansing the throat. 
If the child is not old enough, thorough spraying of 
the throat should be done. A solution of one part of 
the official Aqua Hydrogenii Dioxidi to 3 parts of 
warm water, freshly prepared each time, should be 
used as a gargle, every one and one-half or two hours 
during the day, and every three hours during the 
night. Three or four minutes after this gargle has 
been used, it should be followed by some simple alka- 
line wash, to remove the irritant effects of the hydro- 
gen peroxid. A gargle that may be used for this sec- 
ondary cleansing purpose is a teaspoonful of boric 
acid added to ^ glass of warm water. This will not 
all dissolve, but will deposit on the throat and act 
as a mild antiseptic. Also, there is no greater pro- 
motor of mucous secretion of the throat than boric 
acid ; and the more the mucus is secreted, the quicker 
will the membrane be loosened. Or, a simple solution 
of J4 teaspoonful of salt and ^ teaspoonful of sodium 
bicarbonate may be added to ^ glass of warm water. 
The object of such a gargle and wash is to cleanse the 
mouth and throat of froth and pieces of membrane, 
mucus, mucopus, etc., and to soothe the membrane. 
It is frequently advisable to insufflate boric acid 
directly on the masses of membrane or exudate. This 
should be done by the physician. 

After the throat has been cleansed all that is pos- 
sible, it is often of value to apply tincture of iodin to 
the membrane or exudate. Care must be taken not to 
touch the healthy membrane with this solution. 
Lugol's solution may be applied to the parts of the 



162 TREATMENT OF NASAL DIPHTHERIA 

throat that are not affected, which often tends to pre- 
vent development of more exudate or membrane. If 
there are pockets and crypts in diseased tonsils, after 
cleansing such, boroglycerid may be applied to heal 
and to prevent spreading of infection. 

As frequent gargling is very tiresome for the throat, 
swashing is nearly, if not quite, as efficient, and should 
be suggested. If the child is too young to gargle or 
swash, the peroxid should be sprayed on, and the 
solutions for this purpose should be stronger, namely, 
1 part to 2 parts of warm water. The cleansing spray 
may be used afterward. If the throat and mouth gen- 
erally are irritated, a soothing gargle is as follows : 

Gm. or c.c. 
IJ Acidi borici 2 gr. pcxx 

Potassii chloratis 5 3 iss 

Aquae menthae piperitae 200 flS vii 

M. Sig. : Use undiluted as a gargle, as directed. 

Of course, any other flavor than peppermint could 
be used in this mixture. 

Whether or not it is advisable to use a weak hydro- 
gen peroxid solution in nasal diphtheria is a question 
for individual decision of the physician; generally it 
is too irritant, even when used weak, and is inadvis- 
able. Cleansing mild alkaline solutions or boric acid 
solutions represent the most successful treatment of 
nasal diphtheria used as sprays or snuffed through 
the nostrils. Such mild, warm solutions may be poured 
from a small vial or from a teaspoon into the nostril, 
with the head thrown back. It is inadvisable to use 
any of the douches that are on the market, or any 
syphon douche, as the pressure is too great, and fluid 
is often forced up the eustachian tube or into some of 
the sinuses. Suprarenal extract may be added to 
these solutions, if deemed advisable, but it should not 
be used too frequently. Also, the nose should not 
be sprayed too frequently. 

As soon as the throat is clean, the frequency of the 
gargles should be diminished, but it should be several 



GENERAL MEDICATION 163 

days before the patient is not awakened at night to 
gargle at least once, or better, twice. 

The treatment of the throat advised for diphtheria 
is equally applicable to follicular tonsillitis or scarla- 
tinal throats, and to septic sore throat. 

E. General Medication. — A diphtheria patient 
requires very little general medication, unless some 
complications occur. In the beginning a small dose 
of calomel, or a dose of castor oil may be advisable, 
and subsequently whatever simple laxative is needed to 
cause a daily movement of the bowels. The tempera- 
ture does not often call for treatment. If it is high, 
or there is headache and backache and general aches, 
two or three small doses of a coal-tar antipyretic may 
be given. The following combination for a child 10 
years old is efficient: 

Gm. 

IJ Acetphenetidinl 11 55 orr y-v 

Phenylis salicylatis l| aa gr. xv 

M. et fac chartulas v. 

Sig. : A powder every three hours, if needed. 

Later, if the temperature is high, tepid sponging is 
sufficient, but generally, with the ordinary low tem- 
perature of diphtheria, hot sponging for cleanliness 
and to increase the activity of the skin, and to remove 
the perspiration, should be done once or twice daily. 

As suggested above, every patient with diphtheria 
should receive iron, either the tincture of iron chlorid, 
a few drops in fresh lemonade, or a 3-grain tablet of 
eisenzucker, three times a day, or 0.10 gm. (1}4 
grains) of reduced iron, in capsule, three times a day. 
If there is a tendency for the throat or nose to bleed, 
it can do no harm to add lime water to the diet, and it 
may be of value. 

On account of the nervous depression caused by the 
toxins of the Klebs-Loeffler bacillus, a small dose of 
strychnin, not exactly as a cardiac stimulant, but more 
as a nervous stimulant, is advisable, provided the con- 



164 CARE OF THE HEART 

dition of the patient seems to require it. For a child 
10 years old, 1/60 grain of strychnin sulphate, once in 
six hours, is generally a sufficient dose. If the child 
is made nervous by strychnin, it should certainly be 
withheld. A little coffee or tea may be given a child, 
as a medicine for the action of the caffein, and is of 
value. 

F. Care of the Heart. — Although it was long con- 
sidered that heart failure in diphtheria was due to 
vasomotor paralysis, or to action on the vasomotor 
center, it has been shown by Porter and Pratt^^ that 
such is probably not the case: that heart failure 
is probably due to the action of the toxins on the 
heart itself. Dr. F. W. White of Boston long ago^^ 
showed that the heart was frequently affected more 
or less seriously in diphtheria. White also quotes 
many other authorities showing that myocarditis is 
not an infrequent complication, that valvular dis- 
ease may occur from diphtheria, and that even a 
chronic myocarditis may persist, or a valvular lesion 
may persist for months or even years, or for life. 
White and Smith studied the hearts in a thousand 
cases of diphtheria, and came to the conclusions that 
moderate disturbance of the heart is very common in 
diphtheria, and that persistence of cardiac defects 
often lasts from two to six months ; but generally car- 
diac disturbances from diphtheria become permanently 
cured. The mitral valve is the one most frequently 
diseased, and if a lesion is caused, it is generally 
insufficiency. About 60 per cent, of the patients with 
diphtheria show an irregular pulse, and the younger 
the patient, the more liable he is to have this heart 
irregularity. It may occur even in mild cases. These 
investigators found that out of 1,000 cases 878 had a 
heart murmur of some kind at some period of the dis- 
ease, either at the apex or at the base. The mur- 



22. Porter and Pratt: Am. Jour. Physiol., 1914, xxxiii, 431. 

23. White F. W.: The After-Effects of Diphtheria on the Heart, 
The Journal A. M. A., Oct. 21, 1905, p. 1243. White, F. W., and 
Smith, H. H.: Boston Med. and Surg. Jour., Oct. 20, 1904, p. 433. 



GALLOP RHYTHM 165 

murs were generally systolic. These murmurs usually 
clear up and are not generally significant of valvular 
lesions. The murmur at the apex is doubtless due to 
a relative insufficiency of the mitral valve, because of 
slight dilatation of the left ventricle. In this investi- 
gation, necropsies showed that endocarditis and peri- 
carditis are extremely rare complications in diphtheria. 

Dr. G. M. Smith^* reviews more recent investiga- 
tions, made on the hearts of diphtheria patients. He 
quotes Rohmer as concluding that in diphtheria, patho- 
logic changes may occur in the auriculoventricular bun- 
dle, but that there is no specific action of the diph- 
theria toxin on the bundle of His. However, diph- 
theria toxins may so affect the connecting bundle from 
a functional point of view that heart-block can be pro- 
duced, even without demonstrable anatomic lesions. 

Clinically, the gallop rhythm, with or without vomit- 
ing and epigastric pain and tenderness, is a bad symp- 
tom in diphtheria. This gallop rhythm of the heart 
is very serious, and if accompanied by vomiting, the 
prognosis is very bad. Hume and Clegg,^^ after an 
investigation of 573 cases of diphtheria, declare that 
any form of arrhythmia of the heart (except sinus 
arrhythmia) in diphtheria indicates that the heart mus- 
cle or nerves are pathologically disturbed. This may 
occur even when the diphtheria is apparently mild. 

After a patient is apparently well from diphtheria, 
if he has been severely ill, and especially if the case 
has been neglected and a large amount of toxins have 
been absorbed, cardiac failure may occur any time 
from the second to the fifth week. Symptoms of late 
cardiac weakness are often a slow, weak pulse. Such 
hearts, however, become rapid on the least exertion. 
Such patients are often very pale, and there are liable 
to be more or less gastro-intestinal disturbances. 

24. Smith, G, M.: A Review of Some Recent Publications on 
Anatomy and Pathology, Am. Jour. Dis. Child., April, 1913, p. 322. 

25. Hume and Clegg: Quart. Jour. Med., 1914, viii, 1. 



/ 



166 RAISING OF QUARANTINE 

There can be no question that the effects on the heart 
in diphtheria are due to the Klebs-Loeffler bacillus 
toxins; consequently, if antitoxin in sufficient dose is 
given early, the toxic effect on the heart will prob- 
ably rarely occur. Consequently, cardiac deaths in 
diphtheria will be less and less frequent with the 
early proper administration of antitoxin. 

The most important treatment of cardiac complica- 
tion is rest, and prolonged rest. A patient who has 
shown cardiac inflammation of any kind, or cardiac 
irritation during diphtheria, should have a prolonged 
rest in bed and a very slow convalescence. The small 
dose of strychnin suggested above as a nerve stimulant 
is probably sufficient. If the heart is very rapid, it 
may be unwise to give even this small dose. Larger 
doses do not seem to raise the blood pressure during 
illness, and strychnin in large doses as a cardiac tonic, 
in prolonged weakness, is not so successful as has been 
thought. In an apparently acute failure, a fair-sized 
dose, 1/40 grain for a child 10 years old, may be given 
hypodermically ; but to persist in large doses of strych- 
nin is inadvisable. Digitalis is not indicated, and alco- 
hol should not be given. Caffein and camphor may be 
worth while ; but the main thing is absolute rest, small 
amounts of food, the least possible disturbance for 
bathing, feeding, defecation and urination, and no 
prostrating purgatives. 

G. After Rest. — A patient who has recovered from 
diphtheria, however mild it may have been, should 
have, for the first two weeks, at least, a carefully 
watched convalescence. Strenuous exercise should be 
avoided, and the heart should be carefully examined 
before the patient is allowed to return to his usual 
work, school, or play. 

H. When to Raise the Quarantine. — This has 
already been sufficiently discussed. Boards of health 
vary in their requirements. The safest rule would 
seem to be to release the patient from quarantine after 
four negative cultures have been taken, at least two 



DIPHTHERITIC PARALYSIS 167 

days apart; one of the cultures should be taken from 
the nostrils. The swab specimens should be procured 
by a physician, and should be taken several hours after 
any antiseptic gargles have been used. Also the last 
culture should be taken from back of the tonsils and 
from crypts, if any are present. 

/. Fumigation. — As stated, formaldehyd or other 
fumigation is unprofitable in diphtheria, but may be 
added to thorough germicidal cleaning of the room and 
its contents. This is a decision for the local board of 
health. 

/. Paralysis. — With the early injection of a suffi- 
cient dose of antitoxin, diphtheria paralysis will 
become less and less frequent. The paralysis of the 
soft palate, which used to be so frequent, is already 
becoming infrequent. This paralysis occurs early, 
between ten and twenty days from the beginning of the 
illness. The treatment consists of tonics, small doses 
of strychnin, the best of nutrition, fresh air, sunlight, 
rest, and prolonged convalescence. The general paraly- 
ses, which are now rarely seen, were more serious, and 
occurred later. They are slow in recovery, and besides 
general treatment, require massage and electricity. 

K. Diseased Tonsils. — Quite probably diseased ton- 
sils cause a susceptibility to diphtheria, as they cer- 
tainly do to follicular tonsillitis. After complete recov- 
ery from a diphtheria attack, when the general condi- 
tion is perfect, and the heart is in good condition, 
operations should remove all portions of tonsils that 
show disease. Whether complete enucleation should 
be done, or only diseased portions should be removed, 
and whether or not the capsules should be left, are 
subjects for an expert decision.^^ 

LARYNGEAL DIPHTHERIA 

Membranous croup is laryngeal diphtheria, and as 
soon as the diagnosis can be made that there is exu- 



26. French, Thomas R.: New York Med. Jour., Dec. 5, 1914, p. 1097. 



168 LARYNGEAL DIPHTHERIA 

date in the larynx or laryngeal region, antitoxin should 
be given in large dose, without waiting for a decision 
from the laboratory that the Klebs-Loeffler bacillus is 
present. The only safe place for a patient with 
laryngeal diphtheria is a contagious disease hospital, 
where expert skill in intubation and, if necessary, in 
tracheotomy can be quickly obtained. The main dan- 
ger from diphtheria in this location is suffocation. 

The toxemia is not great, and the absorption is much 
less than in nasal, nasopharyngeal, or even in tonsillar 
diphtheria. 

The best of nutrition is important, as exhaustion 
from labored breathing is likely to occur. The atmo- 
sphere of the room is better moist, on account of the 
membrane becoming dry and causing more obstruc- 
tion before it loosens and is coughed up. Just how 
much local steaming of the throat, or inhalation of 
various medicated solutions should be given, is to be 
decided by the individual physician. The main advan- 
tage is doubtless from the vapor of water. 

The main requirements to be remembered in laryn- 
geal diphtheria are the administration of an immediate 
large dose of antitoxin ; intubation by a skilled operator 
as soon as indicated ; a trained nurse skilled in intuba- 
tion cases, if such can be obtained ; the ability to recall 
quickly the physician who intubated if the tube is 
coughed up ; the immediate removal by the nurse of the 
intubation tube if it plugs up, and the quick per- 
formance of tracheotomy by the surgeon, if such a 
measure is needed. 



SEPTIC SORE THROAT 

For some years there have been reported in England 
epidemics of septic sore throat, some of which have 
been distinctly traced to infected milk, and all of 
which probably develop from that source. In the last 
few years several cities and towns in this country have 
suffered from epidemics of this character, and in 
every instance it has been traced to milk from one 
dairy, and ultimately to one or more diseased cows. 
The disease that causes such infection is an inflamma- 
tion of the milk glands, a mastitis, or an inflammation 
of the udder termed garget. Another possible source 
for the dissemination of this germ is an infected throat 
of the milker, or of some one who handles the raw 
milk. 

The germs found in the inflamed udders, in the raw 
milk, and in the throats of those infected are the same, 
namely, the Streptococcus pyogenes. The largest epi- 
demics have occurred in Boston, Baltimore and Chi- 
cago, and in all, about 25,000 individuals have been 
attacked. The death rate is small, and is due to com- 
plications. An epidemic occurring in Boston is 
described by Winslow,^ the Chicago epidemic by 
Capps,^ and an epidemic in Courtland and Homer, 
N. Y., by North, White and Avery.^ 

The clinical symptoms have been the same in all of 
these epidemics, and Capps states that the throats 
generally show intense hyperemia without a grayish 
exudate. The cervical lymph glands enlarge, and may 
suppurate ; there is extreme prostration, and a tendency 
to relapse. The complications are inflammation of the 
middle ear, abscess around or about the tonsils, and 
erysipelas or other skin eruptions. The most danger- 

1. Winslow: Boston Med. and Surg. Jour., 1911, clxv, 899. 

2. Capps, Joseph A.: Epidemic Streptococcus Sore Throat — Its Symp- 
toms, Origin and Transmission, The Journal A. M. A., Sept. 6, 1913, 
p. 723. 

3. North, White and Avery: Jour. Infect. Dis., January, 1914, 
p. 124. 



170 TREATMENT OF SEPTIC SORE THROAT 

ous and fatal complication is peritonitis, and there may 
be fatal septicemia, with localization in the lungs. 
Endocarditis, myocarditis, arthritis, and nephritis may 
occur as complications in this septic process. 

Means of prevention of septic sore throat in epi- 
demics must include a more frequent bacteriologic 
examination of the udders of cows and of the throats 
of those who handle raw milk. Pasteurization of milk 
would prevent these germs from causing infection. 

The treatment of these septic sore throats is not 
different from that of follicular tonsillitis, namely, 
dilute hydrogen peroxid solutions 1 : 4, immediate sub- 
sequent washings with mild alkaline cleansing solu- 
tions, and the local application of a weak iodin solu- 
tion, as Lugol's solution (too strong iodin prepara- 
tions might increase the swelling and hyperemia of 
the throat). 

On account of the prostration, the patient should 
receive plenty of nutriment. The bowels should be 
moved daily. Pain should be stopped, if it is trouble- 
some, by codein or morphin, if deemed advisable. 
High temperature should be treated as seems best, and 
the complications combated as they occur. Infection 
of others is prevented by the same methods as those 
described for diphtheria. The blood in this disease 
should be studied, not only to determine the amount of 
leukocytosis, and the type that is probably present, 
but also to determine the amount that gives a favorable 
prognosis. Such studies may give a clue as to the pos- 
sible value of an autogenous vaccine. 



MEASLES 

Measles is probably the most frequent of all infec- 
tious diseases, and as many as 25,000 cases have 
occurred in the city of New York in one year. No 
age is immune, although infants under 6 months are 
rarely attacked. Though measles can recur in rare 
instances, it generally confers immunity for life. That 
it is considered such a simple, common disease is 
probably the cause of the large number of deaths 
from neglect. It is estimated that 12,000 deaths a 
year occur in the United States from this disease, and 
the number might be much greater if some bronchial 
and lobar pneumonias were properly recorded as 
directly followed by measles. The greatest number of 
deaths occur in young children. While occasionally 
a death may occur from the intensity of the disease, 
generally death is caused by complications in the 
lungs, abdomen or ear. The complication in the ear 
is middle-ear inflammation with, at times, an exten- 
sion to the mastoid. In the lungs the condition may 
be bronchial pneumonia or pneumonia; or the bron- 
chial glands, which are probably always inflamed in 
measles, may become permanently enlarged. If tuber- 
culous glands are present, general or pulmonary 
tuberculosis, if not considered a complication, is fre- 
quently caused by measles. The glands in the intes- 
tines may become inflamed and cause serious trouble. 
Inflammation of the cervical glands occurs not infre- 
quently. Nephritis is rare. Hemorrhagic skin erup- 
tions occasionally occur. The urine of patients suf- 
fering with measles has been shown to be toxic to 
guinea-pigs; therefore the toxins of this disease are 
circulating in the blood and pass into the urine.^ 

In civilized countries the mortality, though varying 
somewhat in different epidemics, is always greater 

1. Aronson and Sommerf eld : Deutsch. med. Wchnschr., 1912, 
xxxviii, 1733. 



172 ETIOLOGY OF MEASLES 

where children are crowded into dark, damp tene- 
ments, and is often greater in institutions, probably 
from the fact that physical defects are more or less 
likely to be present in institutional children, or at 
least there is often damaged heredity. In civilized 
communities there has been gradually handed down 
more or less immunity to malignant attacks of this 
disease, and it has been observed that when measles 
first reaches uncivilized communities in which measles 
has not before been rampant, the death rate is exceed- 
ingly great. 

Statistics show, that the largest number of cases 
occur in the spring or late fall, and that the sexes are 
about equally attacked. 

Anderson and Goldberger^ have successfully caused 
measles in monkeys by using the blood of a patient 
with measles. They also showed that the nose and 
throat secretions may infect the monkey, but that 
positive results could be obtained from these secre- 
tions only when they were collected during the period 
of eruption. While they do not wish their deductions 
to be considered final, they are pretty well convinced 
that infection from nose and throat secretions dis- 
appears with the approach of convalescence. They 
did not find that the desquamating epithelium from 
the skin lesions carried the virus of measles. 

Lucas^ quotes Hecker* as finding that the virus that 
will infect monkeys is in the blood stream of patients 
with measles twenty-four hours before the appear- 
ance of Koplik's spots, and that the virus remains in 
the blood and can infect monkeys at least thirty-six 
hours after the appearance of the skin eruption. This 
emphasizes what has long been recognized, that the 
greatest infectivity of measles is during the very- 
earliest stages, and generally before the diagnosis has 
been made. 



2. Anderson, J. F., and Goldberger, Joseph: Recent Advances in 
Our Knowledge of Measles, Am. Jour. Dis. Child., July, 1912, p. 20. 

3. Lucas, W. P.: A Review of Recent Work on Measles, Am. Jour. 
Dis. Child., December, 1913, p. 412. 

4. Hecker: Ztschr. f. Kinderh., May, 1911. 



SYMPTOMS OF MEASLES 173 

Goldberger and Anderson^ have shown that the 
virus of measles may pass through a Berkefeld filter, 
may resist desiccation for at least twenty-four hours, 
becomes non-infective after being subjected for 
fifteen minutes to a temperature of 55 C. (131 F.), 
and will resist freezing for at least twenty-four hours. 
With these scientific facts it may readily be seen why, 
clinically, measles is the most contagious, next to 
small-pox, of all diseases with which we are 
acquainted, and the fact that it is most contagious 
almost before the diagnosis can be made renders its 
prevention very difficult. 

EARLY SYMPTOMS 

It is essential, if possible, to make a diagnosis of 
measles before the stage of eruption. After a vary- 
ing period of incubation, averaging perhaps two 
weeks, the first stage of measles is evidenced by an 
acute coryza, attended by considerable sneezing. The 
eyelids become swollen, and the eyes somewhat 
inflamed. The tonsils are generally enlarged, and the 
throat congested. The secretions from the nose and 
throat are at first serous, and later seropurulent. 
There is almost invariably some fever from the begin- 
ning of this first stage, varying in amount, and it is 
generally the highest during the first and second day 
of the complete eruption which, on the average, 
appears on the fourth day. The usual symptoms of 
infection are likely to be present, namely, coated 
tongue, loss of appetite, muscle aches, headache, some 
lumbar pains, chilliness, and in children sometimes 
vomiting or diarrhea. With the appearance of these 
symptoms, measles should always be suspected. 

In no attack of acute illness in a child should an 
examination of the mouth and throat be omitted. A 
careful examination of the mouth will often show 
some punctate red spots on the hard palate, and on the 

5. Goldberger, Joseph, and Anderson, J. F. : The Nature of the 
Virus of Measles, The Journal A. M. A., Sept. 16, 1911, p. 971. 



174 BLOOD IN MEASLES 

mucous membrane of the cheeks will quite generally 
be noticed Koplik's spots, which are diagnostic. 
Though early described by other observers, the spots 
which bear his name were brought to general notice 
by Koplik in 1896. They most frequently occur on 
the cheeks near the molar teeth, and at first appear 
as little darker blotches on the red membrane. Soon 
in the center of these blotches appears a very small 
bluish-white speck slightly raised from the surface. 
These spots never seem to occur on the gums. 
Although there may be but few of these spots, they 
are typical and diagnostic of measles. Many times 
they are not found, but it is probably generally 
because they have been overlooked, or have been very 
few in number and minute. These spots may appear 
two or three days before the eruption on the skin; 
their diagnostic importance is therefore evident. 

One should not be thrown oft his guard during the 
first stage of measles by a sudden dropping of the 
temperature. This sometimes occurs without any 
antipyretic, and has not been explained. In other 
words, the illness seems, apparently, about to cease, 
and suddenly the temperature again rises, and soon 
the skin eruption is present. 

The blood in measles is more or less characteristic. 
There is diminution in the number of leukocytes, that 
is, a leukopenia. Lucas® says that early in the infec- 
tion there is distinct change in the white blood count, 
and that the greater diminution is in the lymphocytes. 
He states that a relative diminution of lymphocytes 
and neutrophilic cells may be noticed a week before 
any visible symptoms of infection occur, and that the 
blood will show positive evidence of this disturbance 
at least forty-eight hours before Koplik spots appear. 
He also finds a great many disintegrated cells in this 
blood picture. Lucas^ also states that different investi- 
gators have shown that the eosinophil cells are dimin- 

6. Lucas, W. P.: The Value of the Blood Picture in the Early 
Diagnosis of Measles, Especially in Relation to the Question of Isola- 
tion, Am. Jour. Dis. Child., February, 1914, p. 149. 



ERUPTION IN MEASLES 175 

ished, and may even disappear entirely from the blood 
of patients during the eruptive stage of measles. 

In pneumonia, in epidemic cerebrospinal meningitis, 
and in scarlet fever the leukocytes are increased in 
number. In typhoid fever and in measles there is a 
diminution of leukocytes, but in these diseases the 
greatest diminution is in the polymorphonuclear cells, 
while the lymphocytes may be relatively increased. 

ERUPTION 

This is most thoroughly described in all its details 
by Lucas.^ The typical eruption of measles is papu- 
lar, begins from the third to the fifth day (generally 
on the fourth), and lasts four or five days, the amount 
varying widely in different cases. It begins on the 
neck and face, then on the back, and then goes to 
the shoulders, arms, abdomen and legs. Besides the 
typical papules, there may be many macules which 
never reach the papular stage. The spots are gen- 
erally of a dull reddish color, and somewhat resemble 
the bites of fleas. They may be irregular in shape 
and coalesce and form patches. A typical distinction 
from scarlet fever eruption is that in scarlet fever 
there is an oval clear space around the mouth. Von 
Pirquet^ believes that the eruption of measles depends 
on the vascularity of the skin, and that the rash 
appears early and is more intense on the parts of the 
skin that have a large blood supply, and in parts that 
are near the large blood-vessels, and he concludes that 
the rash is the result of a "reaction with the measles 
organism or virus which takes place in the capillaries 
of the skin," and may be due to an agglutination of 
the measles organism by the action of its antibodies. 

Prodromal rashes may occur in measles and cause 
difficulty in diagnosis. There may be an erythema 
not unlike scarlet fever patches. These eruptions may 
occur one or more days before the typical eruption 
of measles. They are generally urticarial in type, and 

7. Von Pirquet: Ztschr. f. Kinderh.. 1913, vi, 1. 



176 PREVENTION OF MEASLES 

often represent some acute indigestion or food poison- 
ing, or may be due to some drug that has been admin- 
istered. The diagnosis is made by the catarrhal 
symptoms, by the blood count, by the Koplik spots, 
and by the occurrence of the typical eruption of 
measles. 

There is always more or less desquamation after 
the eruption begins to fade, and the more the erup- 
tion, the more the desquamation. It may last for a 
few days, or may last for one or more weeks. This 
desquamated epidermis is generally in the form of 
fine scales. 

PREVENTION OF INFECTION OF OTHERS 

As stated in the beginning of the discussion of this 
disease, probably few persons escape an attack of 
measles. Therefore, up to recent years, before isola- 
tion measures were inaugurated, most adults had had 
measles, and therefore were immune to the disease. 
With the isolation measures now in vogue, many 
youth and young adults have never had the disease, 
and therefore physicians are having more cases of 
measles to treat in persons who are no longer 
children. 

A large number of cities have now declared that 
measles is a reportable disease, though placarding of 
the houses which contain the disease is not general. 
The isolation required by boards of health varies 
from fourteen to twenty-one days. A longer period 
than two weeks seems entirely unnecessary, as it 
seems probable that infection can be given only in 
the very early stages and apparently not longer than 
the stage of eruption, even by the secretions of the 
nose and throat. The desquamating skin does not 
carry contagium. Therefore, a long quarantine would 
seem an unnecessary hardship. 

A schoolchild being reported as having measles 
should cause the other children in the family and 
tenement to be studied as to whether or not they have 



TRANSMISSION OF MEASLES 177 

had the disease, and as to how close contact they 
have had with the infected child. It would seem 
unnecessary to keep children out of school who have 
already had this disease, since it has not been shown 
that there are carriers of this germ. The children 
who sit in school in the immediate vicinity of the 
infected child should also be studied, as it is posi- 
tively known that the most contagious period of the 
disease is before the eruption, which often means, 
in mild cases, before it is known that the child is ill. 
Children who have not had the disease and who have 
been directly exposed to possible infection from the 
child who is known to have the disease should remain 
out of school and away from other children for a 
period of at least fourteen days. 

It has been shown that the contagium of measles, 
infectious as it is, is transmitted by a more or less 
close contact. In the wards of hospitals measles has 
been treated in box compartments open at the top, 
without giving the contagium to adjoining beds. 

The greatest danger of this disease is to young 
children; therefore when a schoolchild becomes 
infected, although the disease is almost universal in 
civilized countries and the majority of mankind has 
had it or will have it, the greatest of care must be 
taken that other children do not acquire this disease 
and later give it to infants in their households. Con- 
sequently, careful cleanliness and antiseptic measures 
should be used in a room in which the infected cliild 
had his desk. It is probably rarely necessary to close 
a school or a schoolroom on account of measles. 

Physicians who are in university and seminary or 
boarding school towns and see a considerable num- 
ber of the youth of the nation become seriously ill 
with such children's diseases as measles and mumps, 
in view of the well-known fact that these simple dis- 
eases are frequently more serious in older persons 
than in children, often question the wisdom of pre- 
venting the occurrence of such diseases in children. 



178 TREATMENT OF MEASLES 

The answers to such a point of view are: 1. The 
more cases of measles there are, the greater will be 
the number of deaths, especially among infants and 
young children. 2. The more measles there is, the 
greater will be the number of permanently injured 
ears, in spite of good treatment. 

The present hope must be that the germ of measles 
will be discovered and that a vaccine will be elab- 
orated that will cause the individual to be as immune 
against measles as he is now immune against small- 
pox from cow-pox vaccination. 

TREATMENT 

In the first place, if the child is very young, the 
danger from measles is greater. Also, the death rate 
in the summer months is smaller than in the winter 
months. This is because this catarrhal disease so 
readily tends to cause lung and ear inflammations. 
As seen so frequently in many diseases, typically 
pneumonia, the mortality in hospital cases of children 
with measles is greater than in private houses, which 
means that such children frequently come from the 
unhygienic atmosphere and surroundings of tenement 
houses. 

A patient with measles must be isolated. The room 
must be warm, as these patients should not be sub- 
jected to cold drafts or cold air. Chilling is espe- 
cially harmful in measles. This does not mean that 
the air of the room should not be fresh and clean, and 
the ventilation the best possible. 

A. Eyes. — Unless the child is very young and cannot 
wear colored spectacles, the room should not be dark. 
Sunlight is as essential for the welfare of patients 
with measles as it is in any other disease. It is 
absolutely unnecessary, in ordinary cases, to have the 
room black dark on account of the eyes. If the eyes 
are inflamed, the child will cooperate and really enjoy 
using colored spectacles. Of course, when it is time 



COUGH IN MEASLES 179 

for the child to go to sleep, the room may be dark- 
ened, and the glasses removed. 

A saturated boric acid solution may be used as a 
wash on the eyes, and if it seems advisable, some sim- 
ple eye-drops may be used, such as: 

Gm. or c.c. 

IJ Acidi borici |25 gr. v 

Aquae camphorae 15 1 flS ivss 

Aquae q.s. ad 25| flS i 

M. Sig. : Use as eye-drops three or four times a day. 

If the lids tend to stick together after sleeping, 
they should be gently washed with warm boric acid 
solution or plain warm water, and before the child 
goes to sleep the edges of the lids may be anointed 
with thick w^hite petrolatum. 

B. Cough, Etc. — If old enough, the child should 
gargle several times a day with some simple, warm, 
alkaline sedative solution. If the child is not old 
enough to gargle, the throat should be sprayed. The 
nose should also be sprayed occasionally, if it seems 
stopped up. However, it is often well to leave the 
nose alone in measles. Most nasal douching is inad- 
visable, as tending to force fluid or secretions into the 
eustachian tubes. 

Most of these patients require some simple expec- 
torant mixture, although many physicians are losing 
faith in the activity of so-called expectorant drugs. 
There is no safe drug that promotes the secretion of 
the mucous membrane of the upper air passages and 
bronchial tubes more than does ammonium chlorid. 
It is of advantage in causing the cough to be less dry, 
and therefore aiding the expulsion of any mucopuru- 
lent matter that may be in the trachea and bronchial 
tubes. Also, if the cough is excessive from irrita- 
tion, a sedative should be added to prevent the unnec- 
essary coughing. A child 5 years old may receive the 
following : 



Gm. ( 


Df C.C. 






05 


gr.i 


3 




3i 


50 




flSii 


100 




flSiv 



180 DIET IN MEASLES 

IJ Codelnae sulphatis 

Ammonii chloridi 

Syrupi tolutani 

Aquae q.s. ad 

M. Sig. : A teaspoonful, in water, every two or three hours, 
when the child is awake. 

If the child's cough is not excessive or irritable, 
the codein may be omitted from the mixture. As 
soon as the expectoration is more free and there is no 
excessive amount of coughing, the medicine may be 
stopped. A child 10 years old should receive twice 
the amount of codein sulphate, and the ammonium 
chlorid should be increased to 5 gm., and if deemed 
advisable, the sour sirup of citric acid may be sub- 
stituted for the sweet sirup of tolu in amount of 
25 c.c. to the 100 c.c. mixture. 

C. Bowels. — In the beginning of the disease, the 
child should receive a small dose of calomel, 0.05 or 
0.10 gm. (1 to lj4 grains) given with milk; or a dose 
of castor oil, or some rhubarb or cascara ; at least, 
the bowels should be thoroughly and well moved. 
Minute doses of calomel frequently repeated should 
not be given, as such dosage causes irritation and no 
benefit. Subsequently the bowels should be moved 
daily with some gentle laxative, if such is needed. 

D. Diet. — The food depends on the temperature, 
and should be liquid and simple as long as the tempera- 
ture is elevated. As soon as the temperature falls 
to normal, the child should receive good nutritious 
food, and plenty of it. It is inadvisable to give meat 
in any form, including broths, as long as the eruption 
is present. If, as has been suggested, the eruption 
in measles is caused by some irritant circulating in 
the blood, such as occurs in urticaria, representing a 
sort of anaphylaxis, the proper diet comprises cereals, 
milk, and plenty of water. Such little patients are 
better without fruits, as sometimes even orangeade 
or lemonade seems to cause more itching and discom- 
fort of the skin. 



CONVALESCENCE IN MEASLES 181 

E. Fever. — The temperature rarely calls for much 
treatment. If it is high, however, one or two doses 
of acetanilid will generally be sufficient to reduce it. 
Hot sponging will cool the child as much as cold 
sponging will, and with less disturbance. Cold spong- 
ing in measles is inadvisable. As often as the child 
is bathed or sponged for temperature, the surface of 
the body should be powdered with some bland talcum. 

F. Skin. — Unless the room is cold and damp, or the 
patient is otherwise ill, a cotton nightdress will cause 
less itching and discomfort than would a warmer flan- 
nel or silk shirt. All through the illness the nurse 
should recognize that it is the secretions of the nose 
and throat that cause infection of others, and not 
the eruption or exfoliation from the skin. This does 
not mean that it is not necessary to sterilize the 
child's garments and bedclothing, as such may carry 
the infection from the nose and throat. 

G. Convalescence. — Prolonged, careful convales- 
cence is essential in measles. Measles, like whooping 
cough, is often a forerunner of pulmonary tuberculo- 
sis. Probably no attack of measles ever occurs that 
does not cause enlargement and more or less inflam- 
mation of the bronchial glands. If such glands harbor 
tubercle bacilli, they are stimulated to cause an acute 
infection. On the other hand, immediately after an 
attack of measles a patient is doubtless more sus- 
ceptible to infection from tubercle bacilli. Therefore, 
before the child is returned to school the cough should 
have ceased, his weight should be normal, and his 
nutrition should be good. 

Persistent enlarged glands in the neck or elsewhere, 
and adenoid conditions or enlarged tonsils, should all 
be regarded with suspicion. Such conditions are 
liable to be accentuated by an attack of measles, and 
proper treatment should be instituted. A suppurating 
ear must be treated by a specialist until pronounced 
cured and the hearing is as near perfect as possible. 
The physician should remember that most defective 



182 MEASLES 

ears follow measles, scarlet fever and influenza; that 
an acutely infected ear, if immediately correctly 
treated, is generally saved intact; distention and per- 
foration may occur without pain. Consequently, he 
should be ever alert to see that the complication of 
middle-ear inflammation is immediately treated. 



GERMAN MEASLES (RoTHELN, RUBELLA) 

This is a highly contagious germ disease, most fre- 
quently affecting children and youth. It generally 
occurs in epidemics, but a considerable number of 
persons exposed to the disease do not acquire it. 
While the germ has not been discovered, and though 
it is not known just how it is transmitted, the proba- 
bility is that the secretions of the nose and throat are 
the means of spreading the infection. It is doubtful 
if the eruption or the desquamating epithelium carries 
the contagium. The stage of incubation is apparently 
long, averaging perhaps from about ten days to two 
weeks. The stage of invasion is rarely seen, as when 
it is first realized that the patient is ill, the eruption 
is present. The eruption is a maculopapular one, 
reddish, and rarely confluent. The papules are less 
raised than in measles; in fact, many points of erup- 
tion are purely macules. The color is brighter than 
that of measles. It occurs first on the chest and 
face, and then gradually spreads over the body, dur- 
ing the first twenty-four hours. Questioning of the 
person_ attacked often shows that there were slight 
rigors and some backache or headache or feelings of 
indisposition. The temperature is generally slight, 
rarely above 100 F. 

A diagnostic symptom, enlargement of the post- 
cervical glands, is almost invariably present, and these 
are found at the time of the beginning of the erup- 
tion. The eruption lasts but a few days, gradually 
fading, and sometimes leaves points of pigmentation 
or discoloration for some time longer. There may 
be considerable fine desquamation, or desquamation 
may be practically absent. 

Complications are rare, and although the patient 
should be confined to the house, the infection is sim- 
ple, and there are not likely to be any consequences. 



184 GERMAN MEASLES 

It has been stated that the leukocytes are gen- 
erally increased in number and that eosinophils are 
absent or diminished during the period of eruption.^ 
More recently, Hess^ found that "in almost all cases 
of German measles there was a definite increase in 
the lymphocytes, even preceding the appearance of 
an exanthem." Hess suggests that this lymphocytosis 
at the time of the appearance of the rash may serv^e 
to differentiate this disease from scarlet fever. Scar- 
let fever, it will be remembered, shows an increase 
of polymorphonuclear white cells in the early stages. 

This disease requires, ordinarily, no real treatment. 
Simple cathartics should be given, the diet reduced, 
and the patient kept indoors until the eruption has 
disappeared. If the throat is irritated, an alkaline 
gargle should be used. The usual simple methods of 
preventing the infection of others should be car- 
ried out. 

The disease should be made reportable, as it is so 
often confused with regular measles, and rarely has 
been confused with a mild scarlet fever. It is more 
likely to be confounded with various kinds of intes- 
tinal or food poisonings that cause eruption. 

1. Arch, de med. exper., November, 1906. 

2. Hess, A. F. : German Measles (Rubella) : An Experimental Study, 
Arch. Int. Med., June, 1914, p. 913. 



CHICKEN-POX; VARICELLA 

This simple, acute, contagious disease, generally 
very mild, and rarely requiring any medication or 
treatment, need not be mentioned here except that 
it is frequently confused with small-pox. In many 
parts of the United States the frequent occurrence 
of small-pox necessitates that every physician should 
be alert to differentiate these two diseases. The dif- 
ferent points of diagnosis between mild small-pox and 
chicken-pox cannot be better stated than in the paper 
of Dr. H. W. Hill,^ director of the Division of 
Epidemiology of the Minnesota State Board of 
Health. He states that 10,000 cases of small-pox 
occur annually in Minnesota alone, and that this large 
number is due primarily to non-vaccination, and sec- 
ondarily to mistaken diagnoses, allowing the infection 
of others. Hill quotes statistics to show that in one 
investigation over a period of twenty-one years there 
were thirty times as many cases of small-pox and 
nearly two hundred times as many deaths occurring 
in the unvaccinated as in the vaccinated. Health 
boards should ponder this fact, and then act. 

He states that several misconceptions of these two 
diseases are prevalent, namely, that chicken-pox 
occurs only in children; that the small-pox eruption 
does not invade the scalp; that the small-pox erup- 
tion alone invades the palms of the hands and the 
soles of the feet; and that chicken-pox lesions are not 
um.bilicated. All of these points of supposed differ- 
ential diagnosis are incorrect. 

The differential points of chicken-pox and small- 
pox are as follows: 

In chicken-pox: The incubation period is at least 
two weeks. There is no definite history of a pre- 
vious attack of this disease. A history of successful 

1. Hill, H. W.: Journal-l.ancet, January, 1912, p. 1. 



186 CHICKENPOX— SMALLPOX 

vaccination within a few years, or a definite history 
of a previous small-pox causes presumption that the 
disease is chicken-pox. There is usually no history 
of a stage of illness before the eruptive stage. The 
eruption appears in the first twenty-four hours of the 
disease, beginning on the back, chest or face, and 
is most profuse on parts of the skin covered by cloth- 
ing. The eruption appears in successive crops on 
successive or alternate days, so that various stages of 
the lesions may be present at one time. The lesions 
are round and oval, and the margins are not crenated. 
The eruption passes through the following stages: 
1. Macules lasting a few hours. 2. Soft, superficial 
papules lasting a few hours. 3. Clear, thin-walled, 
tense vesicles each lasting a few hours (these vesicles 
may be readily broken and appear cupped or pitted, 
and the weeping vesicle then quickly becomes crusted). 

4. The crusts, lasting a shorter or longer time, depend- 
ing on the treatment (each crop completes its cycle 
from macule to crust in from two to four days). 

5. Pitting may occur, but the pits are few, superficial, 
and often oval. 

In small-pox : There is an incubation period of from 
twelve to fourteen days. There is no definite history 
of a previous attack of this disease, and no history of 
successful vaccination within from five to seven years. 
There is an invasion stage of from two to three days 
with headache, backache, chills, fever, etc. The first 
signs of eruption are on the third or fourth day after 
the onset of symptoms, and the eruption begins on the 
face and wrists, and is most profuse on the skin not 
covered by clothing, and the palms of the hands and 
the soles of the feet are often attacked. The eruption 
develops in one crop, the lesions appearing steadily 
from twenty- four to forty-eight hours, the face lesions 
being usually further developed than those on the 
body. The lesions are round at all stages, and the mar- 
gins are not crenated; all those of the same stage of 
development are usually the same size. The lesions 



PREVENTION OF CHICKENPOX 187 

occur as flea-bite macules lasting twenty-four hours, 
and then as papules which feel "shotty" under the fin- 
ger, also lasting twenty-four hours. The next stage is 
umbilication of the shotty-feeHng vesicles, this last- 
ing from twenty-four to seventy-two hours. Next 
firm, opaque pustules form, each lasting from four 
to six days, and this formation of pus is accompanied 
by what is termed the secondary fever of small-pox. 
Next, firm crusts appear at about the thirteenth day 
of the eruption, the fifteenth day from the beginning 
of the disease. Large, dense scabs form with tena- 
cious, dark-colored plaques, which may last days, or 
even weeks, if the skin is not properly treated. Later, 
where there is marked pustulation, deep pitting 
occurs. 

It is essential that chicken-pox cases should be early 
diagnosed, and that the patient should be isolated. A 
laxative should be given; the diet should be simple 
and without meat; warm baths, and powder to pre- 
vent itching, represent the only treatment generally 
required. Older patients should be cautioned, and 
children should be prevented from picking open the 
vesicles that occur on the face, thus preventing pit- 
ting. Young children should wear celluloid mittens. 



SCARLET FEVER 

No other acute infection varies so much in intensity 
as does scarlet fever. An attack may be so mild as 
to be entirely overlooked, or so serious as to make it 
one of the most dangerous of diseases. The activity 
of the germ of infection varies in different years and 
in different epidemics, some epidemics being character- 
ized by their mildness and some by their intensity. 
This cannot be due to the difference in unprotected 
individuals, but must be due to characteristics of 
the germ in different years. Epidemics are most likely 
to occur in the fall and winter, although isolated cases 
may occur at any time. As the disease occurs most 
frequently in schoolchildren, and most frequently in 
the fall, gradually disappearing in the spring and sum- 
mer, it is quite likely that the seasonal difference is 
related to its spread in the schools and the attacking of 
those who are susceptible, while later in the year all 
of the susceptibles who have been exposed have had 
the disease ; it then gradually disappears, to begin again 
on the larger influx of susceptibles into the schools in 
the fall. Fewer persons are attacked by scarlet fever 
than by measles or whooping cough, which may show 
a natural immunity or insusceptibility. On the other 
hand, some families seem to present hypersuscepti- 
bility, such families having the disease in the severest 
form and with a high mortality. All ages and most 
peoples are susceptible to scarlet fever, but the large 
majority of deaths, stated at 90 per cent., are in chil- 
dren under 10 years of age. Young babies up to the 
age of 6 months, as in most other contagious diseases, 
are not likely to acquire this disease. 

ETIOLOGY 

Until recently it was thought that the erupted and 
desquamating skin carried the contagium of scarlet 



ETIOLOGY OF SCARLET FEVER 189 

fever. Probably, even now, the majority of physicians 
are unwilling to believe that this disease is not diffused 
by the desquamating scales. It has been long consid- 
ered proved that scarlet fever was thus caused because 
clothing or articles in contact with the patient, after 
being put away and long disused without sterilization, 
have caused infection of persons who have later come 
in contact with these articles. The possibility and fact 
that secretions from the nose and throat could have 
contaminated these articles has been entirely over- 
looked. 

A specific germ for scarlet fever has not been dis- 
covered. While the streptococcus plays a distinct part 
in this disease, no form yet isolated has been proved 
to be the cause. That the infective agent occurs in the 
mouth and throat has been shown by injecting mon- 
keys with scrapings from the tongue in the early stages 
of the disease.^ Friedlander^ has published a review 
of the streptococcus findings in the throat and in the 
blood, and the relationship of such streptococci of the 
disease to prognosis, etc. It has not been shown that 
the streptococci found in the throat in scarlet fever are 
different from streptococci that appear in other 
inflamed and membranous throats. Park^ believes 
that streptococci are only a secondary infection in scar- 
let fever. Kolmer* and many others believe that it has 
not been proved that streptococcus immunization has 
any value as a prophylactic measure against this dis- 
ease. 

A fusiform bacillus has been found in the throats 
of scarlet fever patients by Klimenko.^ He also found 
this bacillus in the spleen and liver of five out of seven 
children who had died of scarlet fever. The exact 



1. Jampolis, Mark: Resume on Infectious Diseases, Am. Jour. Dis. 
Child., June, 1912, p. 406. 

2. Friedlander: Interstate Med. Jour., January, 1913, p. 55. 

3. Park: Arch. Pediat., June, 1912. 

4. Kolmer, J. A.: Studies of Streptococcus Antibodies in Scarlet 
Fever with Special Reference to Complement Fixation Reactions, abstr., 
The Journal A. M. A., Dec. 9, 1911, p. 1942. 

5. Klimenko: Russk. Vrach, xiii. No. 8. 



190 ETIOLOGY OF SCARLET FEVER 

relationship of the bacillus to scarlet fever of course 
has not yet been determined. 

Koessler,^ after reviewing experimental study in 
this disease, concludes that "the serum of scarlet fever 
patients contains specific antibodies for an unknown 
virus," and that "this unknown virus seems to be pres- 
ent specifically in the cervical lymph nodes." Schultze^ 
of New York first described a certain micrococcus 
which he had found in the throats of scarlet fever 
patients. It is stated that this micrococcus, which has 
been termed the "Micrococcus S," has been found in 
the mouth only in the early stages of the disease, and 
it is believed that this would prove that scarlet fever 
was contagious only during the early first stage. The 
organism was not found in the purulent discharges, or 
in the blood. While this coccus has been carefully 
described, it is admitted that it is distinguished at 
times with difficulty, and Ferry^ states that it must be 
differentiated from the Micrococcus catarrhalis, the 
Micrococcus tetragenus, the Micrococcus pharyngis 
siccus and from the Diplococcus intracellular is menin- 
gitidis. It has not been proved that the Micrococcus S 
is the cause of scarlet fever, or that vaccines made 
from this germ, or from this germ and streptococci, or 
from streptococci, have curative action in scarlet fever, 
or have immunizing powers against scarlet fever.^ 

To sum up, we must declare that the germ of scar- 
let fever has not yet been discovered ; that there is no 
doubt that the disease is spread by the secretions of 
the mouth, throat and probably nostrils ; that the skin 
does not spread the contagium except as it becomes 
contaminated with these secretions; that the strepto- 
coccus plays a large part in the clinical course of the 
disease of scarlet fever, and that a patient may develop 
an actual septicemia, and this septicemia is frequently 

6. Koessler, K. K. : Recent Advances in Our Knowledge of Scarlet 
Fever, The Journal A. M. A., Oct. 26, 1912, p. 1528. 

7. Schultze: Med. Rec, New York, Dec. 10, 1910. 

8. Ferry: Med. Rec, New York, May 23, 1914, p. 934. 

9. For some apparently satisfactory results see the Medical Record, 
New York, May 23, 1914, two papers. 



PREVENTION OF SCARLET FEVER 191 

the cause of death. It certainly is a frequent cause of 
complications. 

It is thought that scarlet fever is not infrequently 
caused by the milk of diseased cows, and some epi- 
demics of sore throat with eruption have certainly pre- 
sented all the marks of scarlet fever. It should be 
remembered, however, that septic sore throat has been 
scientifically traced to diseased cows, and that in sep- 
tic sore throats, scarlatiniform as well as other erup- 
tions not infrequently occur. It is probable that house- 
hold pets, as cats and dogs, may transmit the con- 
tagium of scarlet fever. 

The secretions of the mouth that carry the germ of 
this disease may infect any article that comes in con- 
tact with the patient, and this specific germ, what- 
ever it may be, can apparently live for a long time 
in spite of heat, cold, drying or moisture, and cause 
infection months, if not years, later. 

The incubation period of this disease is shorter than 
most of the other contagious diseases, and may be as 
short as one day, with an average of about three days. 
If the disease does not occur in the course of a week 
after exposure, the individual will apparently not 
acquire the disease from that contact. 

PROPHYLAXIS 

This primarily presupposes an early diagnosis, and 
such a diagnosis may be very difficult in atypical and 
mild scarlet fever. No single symptom can be 
depended on as diagnostic, and any one or more symp- 
toms may be absent. An association of a reddened 
throat and a strawberry tongue and an eruption typical 
of scarlet fever appearing in twenty-four hours, with 
fever, of course makes the diagnosis positive. Food 
poisoning may cause an eruption similar to that of 
scarlet fever, but would not cause the reddened 
throat. The eruption of measles comes much later in 
the disease. The eruption of German measles may 
simulate the appearance of scarlet fever and is found 



192 DIAGNOSTIC TEST IN SCARLET FEVER 

early, and the diagnosis of German measles from a 
very mild scarlet fever may be difficult unless other 
cases of German measles have occurred, and contact 
with such was positive, and the postcervical glands 
were enlarged ; such a mild case of illness and eruption 
should be considered scarlet fever until proved to be 
caused by some other disease. Even a history of a pre- 
vious attack should not prevent the suspicion, as scarlet 
fever can occur more than once in the same person. 

The following diagnostic test was first suggested 
by Rumpel, in 1909, then more carefully described and 
recommended by Leede,^° and reported by Jampolis^ 
as being present in 199 out of 200 cases. On account 
of having been found in a considerable percentage of 
well persons, it cannot be considered pathognomonic, 
but only a suggestive diagnostic sign. The test is made 
as follows : A passive hyperemia is caused by a broad 
rubber band placed around the arm, just above the 
elbow joint, not sufficiently tight to obstruct arterial 
flow. This band is loosened in about fifteen minutes, 
and the skin on the inner surface of the elbow joint, 
on being stretched until it appears anemic, will show 
petechiae if the reaction is positive. It has been sug- 
gested that this phenomenon is caused by changes in 
the walls of the capillaries. A negative reaction is 
perhaps a greater indication that scarlet fever is not 
present than is a positive reaction that it is present. 
It has not been shown that such a test would not be 
positive in various anaphylactic conditions. 

It has not been shown that any vaccine or antitoxin 
is of value in preventing or curing scarlet fever. 

Much more interesting, and with greater promise 
of value, is the report of W. S. Barker^^ of St. Louis 
that the blood serum of patients who have had scarlet 
fever may be of value when injected into those who 
are ill with the disease. 



10. Leede: Miinchen. med. Wchnschr., 1911, Iviii, 293 and 1673. 

11. Barker, W. S.: Arch. Pediat, August, 1914. 



PREVENTION IN SCHOOLS 193 

The general prevention of this disease in schools is 
very similar to the methods suggested under diph- 
theria, namely: As soon as a case of scarlet fever is 
reported to the board of health and board of educa- 
tion, other children in this family, children in the same 
house or tenement, the child's playmates, and the chil- 
dren who are in close contact with the infected child, 
either in the schoolroom or in classes, must all be 
under suspicion. There is no object in taking any 
swabs from the throat, if the diagnosis of scarlet 
fever is positive, as no specific germ has been deter- 
mined. The throats and tongues, however, should be 
inspected, and the temperature taken, and a record 
made of all possible contacts with the infected child 
within at least forty-eight hours of the child's becom- 
ing ill. It should be ascertained how many of these 
contacts have already had the disease, although, as 
previously stated, it not infrequently occurs more than 
once in the same individual. These contacts or pos- 
sible contacts should not be allowed in school until one 
week from the time of their possible exposure. Chil- 
dren of the family, and frequently those from the 
same house, should not be allowed to attend school 
during the quarantine of the one infected unless they 
are sent to live in some other house or building. The 
measures taken to cleanse and clean the room in which 
the infected child sat are the same as described in 
diphtheria and measles. Fumigation is not needed. 
If more than one child in a given schoolroom comes 
down with the disease, that room might well be closed 
for a period of one week, not that the room could not 
be thoroughly cleansed of the infective germ in twenty- 
four hours, but lest "missed" or mild cases in this room 
will cause the disease in others. As soon as a week 
has passed, children who are well, and have not again 
been exposed to the disease, may return to school. 

The quarantine of a child's home, or of the person 
infected, is of course that prescribed by the board of 
health of the city or town in which the patient lives. 



194 QUARANTINE IN SCARLET FEVER 

It has been the rule to continue the quarantine for 
from five to ten days after desquamation has ceased, 
and in some cities from six to seven weeks is the term 
of isolation ordered by the boards of health. Unless we 
believe that the skin disseminates the disease, such a 
length of time is entirely inexcusable and unjustifia- 
ble. Quarantine should be raised as soon as the throat 
is well, as soon as the fever has entirely disappeared 
and the acute eruption has ceased. When desquama- 
tion is well established or should have occurred 
(sometimes it occurs very late), the patient should be 
released from quarantine, the placard removed from 
the house, and the other children in the family allowed 
to return to school. The desquamating child should not 
attend school because he is in the midst of his conva- 
lescence and is not yet safe from possible nephritis. 

Although in all probability the infective germ does 
not live long in the secretions of the throat after the 
acute stage is over, it has been thought that continued 
suppuration, whether in the tonsils, nose, sinuses, ear 
or glands, could cause scarlatinal infection of others. 
This is probably doubtful; but children with such 
suppurations should not only be properly treated and 
of course excluded from school, but also kept for a 
time from playing with other children. 

There seems to be no good excuse for preventing 
the wage earners of a family in which the patient is 
at all properly isolated from attending to their ordi- 
nary vocations. A schoolteacher, a nurse, an atten- 
dant on other children, or one who is employed in 
some public institution should stop work temporarily, 
but after one week of observation without other con- 
tact with scarlet fever they may be allowed to resume. 

In view of the belief that the infection occurs in 
the mouth, throat and nose, persons exposed to this 
disease should use gargles or sprays in the throat and 
sprays in the nostrils of some mild antiseptic solution 
three or four times a day for at least four days. 



SYMPTOMS OF SCARLET FEVER 195 

SYMPTOMS 

This disease has a rapid invasion, except in very 
mild cases, with fever, sore throat, not infrequently 
vomiting, and there may be a convulsion in young 
children. The condition of the throat and the height 
of the temperature will give a quite definite indication 
of the severity of the disease, although mild cases may 
have very serious or troublesome complications. On 
the other hand, the temperature may be very high, and 
the type of the disease may be malignant. 

Typically the eruption appears at the end of the 
first day, but may be present when the patient is first 
seen. It generally begins on the neck and chest (it 
may begin on the abdomen, or in the groins and axil- 
lae) and rapidly spreads over the whole body, and in 
a typically severe case the patient presents a scarlet 
hue from the forehead to the feet, and in this form the 
eruption is unlike that of any other disease. This 
bright color may gradually become darker, and in two 
or three days begins gradually to disappear. At its 
height the skin is markedly hyperemic, and any pres- 
sure renders it pale and anemic ; but on removal of the 
pressure the color instantly returns, which is quite 
characteristic of this eruption. As soon as the acute 
stage of the eruption is past, the skin becomes rough 
and dry, and sooner or later desquamation begins, 
ordinarily the rash having entirely disappeared at the 
end of about a week. Punctate eruptions may be 
found in the roof of the mouth, very different from the 
Koplik spots found in measles, and the same reddish 
points may be found in the armpits and groins. 

Unfortunately, the typical eruption described is often 
not present. The eruption may occur in patches, or 
on the chest only, or on or around some of the joints, 
and in mild cases the color of the eruption is not 
typical. Various irritations caused by food or drugs 
and various septic poisonings may produce eruptions 
that simulate that of scarlet fever. Frequently a 
doubtful case may be diagnosed by an associated 



196 DIAGNOSIS OF SCARLET FEVER 

inflammation of the throat, sore throat being absent 
in food and drug poisonings ; but a septic sore throat 
may be associated with scarlatiniform eruption on the 
chest and abdomen. The cause of this eruption in 
many cases, however, is doubtless the drugs that have 
been administered, such as salicylic acid in some form, 
or some coal-tar product, or perhaps quinin. Some 
slight papular eruption may occur in scarlet fever, 
and there may be petechiae, and if the disease is 
malignant there may be large ecchymotic patches. 

Many attacks are so mild that the diagnosis has not 
been made until desquamation begins; and, unfortu- 
nately, even desquamation may not occur, although 
desquamation may occur without much rash or erup- 
tion. Not infrequently a second desquamation may 
occ'ur after the first has been practically completed. 
If the inflammation of the skin has been severe, not 
infrequently the epidermis cornes off in pieces and 
patches, especially on the palms of the hands and the 
soles of the feet. Desquamation usually begins on the 
part first erupted, namely, on the chest and neck. It 
may be prolonged and tedious and last several weeks. 

The characteristic tongue and the characteristic throat 
of scarlet fever need not be described, especially as 
they so greatly vary in appearance. The typical straw- 
berry tongue may not be present. Also Kerley^^ states 
that the strawberry tongue is of little value: "I have 
seen it in many other illnesses." The inflammation 
of the throat may vary from simple redness of the 
tonsils, pharynx and soft palate to masses of mem- 
brane in these regions and in the nasopharynx. These 
so-called anginoid cases are always serious and more 
likely to cause complications and septicemia. It may 
well be noted here that it has been repeatedly stated 
that scarlet fever may occur without any eruption on 
the skin; therefore a suspicious throat and tongue, 
with diphtheria excluded, may be an atypical scarlet 

12. Kerley, C. G. : Personal Observation in Scarlet Fever, The 
Journal A. M. A., Oct. 24, 1908, p. 1407. 



BLOOD IN SCARLET FEVER 197 

fever. However, with our better understanding of 
septic sore throat, real scarlet fever without eruption 
is probably exceedingly rare. 

The fever does not always cease with the eruption, 
and the patient may have a more or less prolonged, 
tedious fever, even without definite complications. 
Generally this fever is due to a septic suppurative proc- 
ess, and will persist until the pus is evacuated, whether 
it is in a gland, a sinus, an ear or elsewhere. Nasal 
and nasopharngeal inflammations cause the tempera- 
ture to persist long. Relapse in scarlet fever is rare, 

THE BLOOD 

A few years ago Dohle^^ stated that he had found 
in the blood of thirty scarlet fever patients "certain 
inclusion bodies" in the polymorphonuclear leukocytes, 
and thought that they might be pathognomonic of 
scarlet fever. He did not find these after the sixth day. 

Kretschmer^* confirmed Dohle's findings, and Nicoll 
and Williams^^ also found these bodies in the blood 
smears of a majority of scarlet fever patients, namely, 
forty-five times in fifty-one cases. That these bodies 
are pathognomonic of scarlet fever was soon denied 
by Ahmed,^^ who found them in other septic processes. 
Later, MacEwen^'^ showed that without doubt strepto- 
coccic infection plays a positive part in causing these 
inclusion bodies, but that a differential diagnosis of 
scarlet fever from measles and German measles may 
be aided by finding these bodies in conjunction with a 
leukocytosis. In measles, it will be remembered, there 
is a leukopenia. Still more recently, Isenshmid and 
Schemensky^^ have concluded, after reviews and inves- 
tigations, that these inclusion bodies are found in the 
polymorphonuclear leukocytes in practically all cases 
of scarlet fever in the early stage. They are not found 

13. Dohle: Centralbl. f. Bacteriol., Nov. 23, 1911. 

14. Kretschmer: Bed. klin. Wchnschr., March 11, 1912. 

15. Nicoll and Williams: Arch. Pediat., May, 1912. 

16. Ahmed: Berl. klin. Wchnschr., June 24, 1912. 

17. MacEwen: Jour. Path, and Bacteriol., 1914, xviii. No. 4. 

18. Isenshmid and Schemensky: Miinchen. med. Wchnschr., 1914, 
Ixi, 1997. 



198 COMPLICATIONS OF SCARLET FEVER 

in diphtheria, measles, German measles or whooping 
cough. They may be found in pneumonia, and per- 
haps in various septic infections. These inclusion 
bodies may be of different forms, but the most char- 
acteristic form is triangular with a long tail-like end. 

There is always a leukocytosis of the polymorphonu- 
clear cells in scarlet fever. It begins early, reaches its 
maximum at the height of the disease, and then gradu- 
ally diminishes, unless there is some septic compHca- 
tion. If the leukocytosis is high, the disease is either 
very severe, or there is pus formation somewhere. 
Tileston, in his investigations of the blood of scarlet 
fever patients, found that the eosinophils were "dimin- 
ished at the height of the fever and eruption, and grad- 
ually returned as the rash disappeared. He did not 
find that any prognostic inferences could be made from 
the number of eosinophils as suggested by Bowie.^^ 

Dick and Henry ^^ have found that the kind of organ- 
isms present in the throat and in blood cultures have 
also been discovered in the urine of scarlet fever 
patients, and they suggest that possibly the frequency 
of nephritis is due to the excretion of these living bac- 
teria through the kidneys. 

COMPLICATIONS 

Complications are so many, and some of them occur 
so frequently, as to be almost a part of scarlet fever, 
and as many times they are the cause of death, they 
deserve more than passing mention. The seriousness 
of anginose scarlet fever has already been mentioned. 
The treatment of such a septic throat is not different 
from that already described for diphtheria. Nasal 
inflammation is a frequent concomitant symptom of 
serious scarlet fever, and frequently one or more of 
the adjacent sinuses are affected. Even in young chil- 
dren in whom the sinuses have been considered ana- 
tomically unimportant, they are likely to become 

19. Bowie, J. M.: Jour, Path, and Bacteriol., March, 1902. 

20. Dick and Henry: Jour. Infect. Dis., July, 1914. 



ALBUMINURIA— ADENITIS 199 

infected, not only the maxillary sinus and the ethmoid 
cells, but even the frontal and sphenoidal sinuses. 
Hubbard^^ discusses these sinus complications, and 
quotes Killian as believing that some form of sinusitis 
is nearly always present when there is any severe rhini- 
tis in scarlet fever. The danger of these inflammations 
of the various sinuses, especially of the ethmoidal and 
sphenoidal cells, is that a septic phlebitis or meningitis 
may occur, which conditions are of the most serious 
prognosis. Hubbard states that "meningeal invasion is 
less likely to follow ethmoidal than frontal sinus 
empyema." Even at tha best when one of the sinuses 
adjacent to the nostrils becomes inflamed and suppu- 
rative, the condition is likely to become chronic and to 
heal slowly, even under the best treatment, to say noth- 
ing of the danger of bone necrosis. 

Any method of treatment of the nose and throat 
that prevents clogging or blocking of discharges in the 
nose or nasopharynx tends to prevent sinus complica- 
tions and middle-ear complications, and the frequency 
of the latter (namely, middle-ear inflammation) in 
scarlet fever is too common to require comment. 

Next in frequency to nose and ear complications are 
involvement of glands of the neck. These glands 
readily suppurate during, or after, scarlet fever. This 
is distinct from the enlargement or inflammation caused 
by diphtheria. With no other apparent cause for the 
persistence of fever, when the eruption is abating, an 
enlarged gland should cause suspicion (especially if 
there is an increase in leukocytosis), that pus has 
already formed in this gland. 

While albuminuria is frequently present during the 
height of the temperature, the complication of nephri- 
tis is not likely to occur before the end of the second 
week, and may even occur as late as the fourth week, 
and this complication not infrequently occurs after 
mild attacks of scarlet fever. Nephritis is stated to 

21. Hubbard, Thomas: Accessory Sinus Suppuration in Scarlatina, 
Am. Jour. Dis. Child., July, 1911, p. 11. 



200 TREATMENT OF SCARLET FEVER 

occur in from 10 to 20 per cent, of all cases. While a 
mild albuminuria and even a few casts may not infre- 
quently be found, a real attack of a complicating neph- 
ritis is always serious. The concomitant symptoms are 
those of nephritis, and the prognosis and treatment is 
that of acute diffuse nephritis. 

Cardiac complications of scarlet fever are not fre- 
quent, but in septic cases serious endocarditis or peri- 
carditis may occur. Not infrequently one or more 
joints may be attacked and may suppurate. Suppura- 
tion of the joint is a serious complication. 

TREATMENT 

A. Isolation. — Strict isolation measures, already dis- 
cussed under other headings, are most important in 
this disease, and the nurse should distinctly under- 
stand that it is the secretions of the mouth and nose, 
and perhaps suppurating complications, that carry 
infection. Also, she should understand that the great- 
est possible care to disinfect or sterilize articles con- 
taminated by such secretions should be exercised, 
as the infecting germ is persistent and lives for a 
long time unless killed. The best equipment of the 
most appropriate room available for the care of the 
scarlet fever patient needs no further discussion. Sun- 
light is essential, ^ as in all infectious diseases. The 
most efficient cleanliness of the patient, the nurse, 
and the physician who handles the case is also essen- 
tial. If a child in a tenement house or in a house 
where there are other children cannot be properly 
isolated, he should be sent to a contagious-disease 
hospital, if there is such. 

B. Diet, etc. — As in the beginning of all diseases, 
especially the infectious diseases, the bowels should 
be thoroughly evacuated with castor-oil, calomel, or 
whatever the physician deems best ; subsequently, they 
should be moved daily by some gentle laxative, found 
efficient. If the patient has diarrhea, it is generally 
caused by a mistake in the diet. Milk is the best 



DIET IN SCARLET FEVER 201 

basis for the diet in scarlet fever. Intestinal indiges- 
tion is not frequent. Foods that add products to 
the blood that during excretion are likely to cause 
irritation of inflamed kidneys should be avoided. 

It is open to discussion whether a mild nephritis 
is a complication of scarlet fever or a part of the 
disease. We beUeve it is a part of the disease, and 
a logical part of it. Whether germs or toxins are 
excreted by the kidneys and irritate them, as has 
been suggested, it is certain that when the skin of 
one-third or more of the body is inflamed, becomes 
dry and does not properly secrete or excrete even 
water, the kidneys almost invariably become irritated, 
if not inflamed. Theoretically, the more intense the 
inflammation of the skin, the greater the amount 
of desquamation, the greater the amount of chilling 
of the body, and the greater the amount of decom- 
position products of protein metabolism, the more 
the liability to nephritis. The aim of the physician, 
therefore, should be to diminish the inflammation 
and irritation of the skin, to keep it warm, to attempt 
to keep it moist and promote its secretion, and to 
give a diet rather low in proteins and without meat, 
meat extractives or purins. Also, if possible, no 
drugs should be administered that tend to irritate 
the kidneys, especially after the first week of the 
illness. Such drugs are coal-tar products, synthetic 
products, caffeins, and any of the drugs that are 
known as stimulant diuretics. Even drugs that con- 
tain salicylic acid should be avoided. 

The diet, then, in scarlet fever first depends on 
the amount of fever and the severity of the illness. 
The greater the intensity of the disease, the more 
liquid the diet should be. While milk is the basis, 
thin cereal gruels are advisable from the start. It 
should not be forgotten that death in many an acute 
disease is now known to have occurred from acidosis, 
due to a protein and albuminous diet and to with- 
holding starches and sugars. Malted milk may be 



202 FEVER IN SCARLET FEVER 

added to this diet, and lemonade or orangeade or 
oranges, as deemed advisable. Later, toasted bread, 
crackers, and various kind of cereals, and still later, 
baked potato, rice, corn starch, and many other cereal 
and milk foods, as well as a greater variety of fruit, 
should constitute the diet. 

As soon as the convalescence is established, and 
even before, if the disease is prolonged, a small dose 
of iron should be given daily, as on the above diet 
the blood cannot get this nutriment. A sugar of 
iron (saccharated oxid of iron) 3-grain tablet should 
be given from one to three times a day. Sodium 
chlorid should always be given a patient from the 
beginning, once or twice a day, in one or more of 
the feedings. If there is a tendency of the nose and 
throat to bleed, or there are hemorrhages in any 
other part of the body, lime-water should be added 
to the diet. The patient should always receive plenty 
of water. If any apparent irritation of the kidneys 
occurs, it may be well to withhold some of the fruits 
and to temporarily diminish the amount of food. 

C. Fever. — The temperature can be very high in 
scarlet fever and represent a dangerous factor in 
the disease. If the bowels are properly moved, and 
the diet is carefully regulated, and the throat, nose 
and nasopharynx are kept as clean as possible to 
reduce the secondary streptococcic infection, the tem- 
perature will be much lower than when these causes 
of increased temperature are neglected. 

If the temperature becomes very high it may be 
advisable to give several doses of an antipyretic, such 
as acetanilid, antipyrin, or acetphenetidin, always bear- 
ing in mind the irritant effect of these drugs on the 
kidneys. Hot sponging of the body will also tend 
to reduce the temperature and make the patient com- 
fortable. It relieves itching, and many times is sooth- 
ing. Cold sponging in scarlet fever is inadvisable 
and uncalled for. If the fever is excessive, tepid 
sponging may be tried. Restlessness and sleeplessness 



CARE OF THE THROAT AND NOSE 203 

will also increase the fever, and often a few doses 
of sodium bromid will be of great benefit. It not 
only causes the patient to sleep, but reduces the 
irritability of the peripheral nerves. Also, anything 
that relieves itching or burning of the skin will reduce 
the temperature and the irritability. Quinin is inad- 
visable, as it is excitant to the brain and may tend 
to congest the ears and add one more element that 
may cause middle-ear complications. An ice cap to 
the head, unless actual meningitis is present and the 
hair is clipped close to the scalp, is inadvisable. 
Whether ice caps to the head ever reduce general 
temperature is open to grave doubt. If there is men- 
ingitis, they may relieve the local congestion. We 
doubt if they are ever of much value in general high 
temperature. In this form of treatment the ice cap 
should be applied whenever the patient is sponged 
with cold water. Ice caps, however, tend to fall to 
one side or the other of the head and unnecessarily 
chill the ears, and may become another factor in caus- 
ing middle-ear inflammation. The value of an ice 
bag over the mastoid when it is in danger is not under 
discussion; but an ice cap over an external ear is 
not called for, and may do harm. 

D, The Throat and Nose. — Antiseptic, alkaline and 
cleansing gargles and sprays for the throat and nose 
are not different from those described under diphtheria. 
The value of boric acid, both in mixture and as 
insufflated powder, is the same as in diphtheria. The 
cleaner the nose and throat in scarlet fever, the less 
the secondary infection, the less the toxemia, and the 
less the danger. Whatever method is used to clean 
the nostrils, such pressure of the liquid as would 
tend to force infection into one or the other of the 
sinuses must never occur. If there is no purulent 
discharge from the nostrils, it is inadvisable to spray 
or douche them, as much harm can be done from too 
strenuous or unnecessary treatment of the nose. 



204 CARE OF THE SKIN 

E. The Skin. — Whatever the temperature, hot spong- 
ing for cleanhness once or twice a day is of advantage, 
is soothing, and advisable. Whatever the tempera- 
ture, sponging with alcohol in any form is inadvis- 
able. Alcohol, unless the solution is so dilute as to 
represent not alcohol, but only an alcoholic odor, will 
tend to dry the skin, cause more itching, and more 
discomfort. The more moist the skin, or the more 
natural oil that is excreted on the skin, the healthier 
it is. Also, we believe that the less the skin is dried 
and rendered nonsecreting, the less likely is the danger 
of a kidney complication. Sometimes sponging with 
bicarbonate of soda in warm water soothes the irri- 
tability and stops the itching. Powdering with some 
soothing talcum powder often stops itching and quiets 
the patient. 

As soon as the acute eruption is over and desquama- 
tion is about to begin, the gentle rubbing into the 
skin of some bland oil, as cocoanut oil or almond oil 
or wool- fat, sometimes with a little glycerin and water, 
hastens the removal of the dried epithelium, prevents 
scales from flying about (although these scales do 
not carry the contagium) and is very quieting to 
the patient, by preventing the irritation and itching. 
As soon as convalescence is established, a more active 
massage of the skin and muscles is advisable. 

The use of mercuric chlorid or phenol solutions 
of any strength, or phenol ointments, on the skin, 
is inadvisable and inexcusable. Most of these solu- 
tions tend to dry the skin still more; the use of 
phenol ointment might result in some absorption and 
therefore is of danger to the kidneys. Also, as it 
seems to be a fact that the contagium is not spread 
by the skin, there is absolutely no excuse for germi- 
cidal ointments or applications. 

Unless the temperature is very high and head symp- 
toms are present, it is unnecessary to cut the hair 
close to the scalp. If the scalp itches, as it often 
does, some simple sedative solution may be used, 



HEART IN SCARLET FEVER 205 

Later, a simple gentle shampoo may be given and a 
little petrolatum rubbed into the scalp. A tar soap 
may stop the itching. Oil of eucalyptus has been 
recommended and used as a non-irritant application 
to the skin and scalp. Also, throats have been swabbed 
with oil of eucalyptus preparations, in the belief that 
eucalyptus oil is especially antiseptic in throat con- 
tagions. 

F. The Heart. — Cardiac stimulation, especially in 
children, is rarely needed in this disease. The toxin 
of this disease is not as depressant as is that of diph- 
theria, and strychnin is generally inadvisable as it 
causes too much cerebral stimulation, especially in 
children. Death from this disease generally occurs 
by its very intensity, or from some complication, and 
is not from prostration and shock. In the malignant 
or fulminating form of this disease, in which death 
may occur on the first or second day, the temperature 
is generally excessively high, and the pulse may be 
rapid and feeble, but stimulation of the heart would 
even then be of but little value. Patients afflicted with 
this type of scarlet fever often have convulsions, and 
generally die in coma. Such deaths are often like a 
fulminating cerebrospinal meningitis. 

On the other hand, if a long septic process follows 
scarlet fever, or there is later a septicemia, small 
doses of strychnin may be of value, and alcohol is of 
value as not only adding a food, but as tending to 
prevent a dangerous acidemia. Also, in such septic 
conditions, as much carbohydrates should be given as 
the patient can digest. 

If joint complications occur, there is more likely to 
be an endocarditis, and perhaps chorea may develop. 

G. Later Complications. — Inflammations in the 
nose and its adjacent sinuses have already been suffi- 
ciently discussed. Middle-ear inflammations should 
be expected and watched for. The drums should be 
early punctured if there is pressure, and the services 
of an expert on diseases of the nose, throat and ears 



206 TREATMENT OF LATE COMPLICATIONS 

should be early sought by the physician, if any of these 
complications occur. 

It may here be emphasized that it has been proved 
that hexamethylenamin (urotropin) can be of no value 
in these throat, nose, sinus, ear, or even meningitis 
cases as it will not furnish formaldehyd and therefore 
cause antiseptic action, except in acid secretions or 
solutions. Also, it is a fact that it can more or less 
irritate the kidneys ; therefore, in scarlet fever through- 
out its entire course this drug should not be given. 

The glands of the neck are almost always congested 
and enlarged in scarlet fever, and one or more may 
tend to suppurate. It often seems that the local appli- 
cation of a proper-sized ice bag to a gland, if the 
patient will tolerate such an application, aborts serious 
inflammation. However, if such a suspicious gland 
continues to enlarge, the temperature rises and blood 
counts show an increasing leukocytosis, there is prob- 
ably pus formation, and the gland should be soon 
opened. The surgeon, however, often decides that he 
prefers to have warm applications for a short time to 
cause more rapid breaking down of the central suppu- 
rating portion of the gland, so that more complete 
evacuation may occur on incision. The subsequent 
dressings and treatment of such an abscess are purely 
surgical. The temperature will generally drop after 
the evacuation of the pus, unless there is some other 
localized septic process. 

Although the percentage of occurrence of nephritis 
in or following scarlet fever is not great, it occurs 
sufficiently often to be always looked for and expected. 
As above urged, all drugs that irritate the kidneys, 
and all foods that cause irritation should be withheld. 
While it has not been shown that meat will cause 
nephritis, it is not necessary to add meat to the diet 
in scarlet fever. Many believe that eggs should not 
be allowed. The withholding of eggs as a preventive 
of nephritis hardly seems necessary. Some physicians 
even withhold salt from the food; this does not seem 



CONVALESCENCE IN SCARLET FEVER 207 

necessary. If the amount of urine greatly diminishes 
and albumin appears, there may not be an actual 
nephritis, but it may be well to attempt to forestall 
or abort such an inflammation. Hot packs or appli- 
cations to the lumbar region can do nothing but good. 
A general body sweat is entirely inadvisable, and the 
value of profuse sweating in uremic conditions is even 
quite doubtful. Perhaps the best preventive of neph- 
ritis is prolonged rest in bed for at least a week after 
the fever has ceased, as it seems to be a fact that the 
better the action of the skin, the less likely are the kid- 
neys to become inflamed, and the skin will be warmer, 
and is likely to be more moist in bed than when the 
patient is about. Chilling of the body following scar- 
let fever is an important added cause for the develop- 
ment of nephritis. Also, if the kidneys have been 
sufliciently irritated to cause a distinct predisposition 
to nephritis, an increased use of the muscles, whether 
by playing, exercise, or work, too soon after the 
acute symptoms are over, may so increase the excre- 
tory substances from muscle metabolism as to add 
a very tangible factor to further irritation of the kid- 
neys and consequent nephritis. If nephritis develops, 
the treatment becomes that of acute B right's disease. 
H. Convalescence. — As just suggested, the patient 
should remain in bed one week after the fever has 
ceased, and the subsequent convalescence should be 
prolonged and carefully watched. During the acute 
stage of the disease the urine should be examined 
daily, to note the first appearance of albumin and how 
long it persists. During the convalescence the urine 
should be examined at least every other day for two 
weeks, and once or twice a week for several weeks 
more. The diet should be increased and most foods 
allowed, except that it may be well for at least two 
weeks not to give meat. During this period the 
patient should continue to receive iron. A simple bit- 
ter tonic may be advisable to stimulate the appetite. 



208 SURGICAL SCARLATINA 

If the weather is cold and damp, great care must be 
taken that the patient be not exposed. 

Just how long the germ of infection persists in the 
mouth, and especially in the nose, has not been deter- 
mined, but secondary cases can occur when the patient, 
especially if he has a nasal discharge, has been allowed 
to play with other susceptible children. It was long 
thought that the desquamating skin was the cause of 
this late infection of others. 

As it is conceded that streptococcic infection is 
concomitant with the cause of many of the complica- 
tions of scarlet fever, vaccine treatment with stock 
vaccines or autogenous vaccines has been suggested 
and advised to hasten the eradication of left-over 
septic processes. The same rules and regulations, and 
the same frequency of success will doubtless occur in 
the septic processes following scarlet fever as with 
any other septic process. 

SO-CALLED SURGICAL SCARLATINA 

Although this name has long been given to eruptions 
that occur during a septic infection, it is very doubtful 
if they bear any relation to scarlet fever. If real scar- 
let fever occurs after an operation, the infection prob- 
ably had nothing to do with the operation or the septic 
process. That the eruptions from septic processes are 
probably not scarlatinal was well proved ten years 
ago by Alice Hamilton. ^^ 

22. Hamilton, Alice: Surgical Scarlatina, Am. Jour. Med. Sc, 
July, 1904, p. Ill; abstr.. The Journal A. M. A., July 23, 1904, p. 
283. 



CEREBROSPINAL FEVER 

EPIDEMIC CEREBROSPINAL MENINGITIS; SPOTTED FEVER 

This disease occurs in epidemic and sporadic forms, 
the latter form being often difficult to diagnose. The 
epidemics are generally small in number of affected 
persons and more or less localized. While young chil- 
dren and young adults are most often attacked, it 
occurs not infrequently in camps, or in other groups 
of closely associated individuals. Hardship, privation, 
exhaustion and poor sanitation seem to allow it to 
occur. The sporadic form is always more or less 
present in most cities, and so-called "basillar menin- 
gitis" is doubtless generally this disease. Some epi- 
demics in cities show a large number of very young 
children affected by it. Epidemics appear, both in this 
country and in Europe, most frequently in the winter 
and spring months, and the greatest number of 
sporadic as well as epidemic cases occur during March, 
April and May. 

ETIOLOGY 

The cause of epidemic cerebrospinal meningitis is 
the Diplococcus intracellularis meningitidis, also called 
meningococcus, which was first described by Weichsel- 
baum, in 1887. These cocci are found in the spinal 
fluid. In appearance they are very much like gono- 
cocci, and lie in pairs either in or near the leukocytes. 
These germs are also found in 'the secretions of the 
nose and nasopharynx. They have been found in the 
blood stream, in the lungs, in the joints, and in other 
parts of the body. The meningococcus is of low 
vitality and is readily killed by sunshine, drying and by 
freezing; therefore, with ordinary precautions the 
danger of contagion is slight. As in so many other 
diseases, carriers of this germ have been found, and 
they probably play a considerable part in the spread 



210 ETIOLOGY OF MENINGITIS 

of epidemics and in the occurrence of sporadic cases. 
In those suffering from this disease the germ has also 
been found in the conjunctiva, and even in the pleura, 
and the meningococcus has been found in some 
instances^ in the lungs of those who have had pul- 
monary inflammations without meningitis. The fre- 
quency with which this germ has been found in con- 
tacts has greatly varied, Goodwin and von Schelly^ 
having found it in the nasal secretions in as many 
as 10 per cent, of contacts. 

The way in which these germs in the nasopharynx 
reach the meninges and cause cerebrospinal fever has 
long been discussed. It seems probable, as they are 
early found in the blood, that the blood stream is the 
method of conveyance, although the possibility, espe- 
cially in young children, of their reaching the meninges 
through the sphenoidal sinuses and first causing peri- 
hypophysial inflammation has been long considered 
and discussed. It is also possible that the blood may 
spread the infection from the bronchial mucous 
membrane. 

Flexner^ produced meningitis in monkeys by inject- 
ing the infection intraspinally, though injections into 
the blood by other investigators had not caused the 
disease. 

From these facts meningococcus cerebrospinal men- 
ingitis should be made a reportable disease, whether 
occurring in sporadic or epidemic form, and carriers 
should be sought, and when discovered, isolated and 
treated. 

SYMPTOMATOLOGY 

The disease generally begins suddenly, although 
there may be such prodromes as aches and pains, 
especially in the head, with a general feeling of weari- 
ness. Soon the headache becomes intense, and most 
severe in the back of the head. This headache is 



1. Jakobitz: Ztschr. f. Hyg. u. Infections krankh., 1907, Ivi, 175. 

2. Goodwin and von Schelly: Jour. Infect. Dis., 1906, p. 21. 

3. Flexner: Jour. Exper. Med., 1907, ix, 142. 



SYMPTOMS OF MENINGITIS 211 

accompanied by fever, generally there is vomiting, and 
there may be early, in fulminating cases, delirium and 
stupor. Soon there is pain in the back of the neck, 
with more or less stiffening of the muscles, and tender- 
ness and pain along the spine. Pain in the extremities 
and body occurs, stiffening of muscles or groups of 
muscles, and convulsive movements may be present. 
Deafness is a frequent symptom. Ringing in the ears 
may be present. The vision may be disturbed. The 
disease may be so rapid as to cause death within 
twenty-four hours or even less, but the usual duration 
is from two to four weeks. Even when the disease is 
protracted six weeks or more, death may still occur. 
In prolonged cases a peculiar intermittency or remis- 
sion of symptoms often occurs. 

Herpes frequently occurs on the mouth or face. The 
frequent occurrence of petechiae has given this disease 
the name of "spotted fever." Other eruptions, of 
urticarial type principally, often occur. The spleen is 
generally enlarged; the appetite is almost absolutely 
lost; there may be very obstinate constipation, rarely 
diarrhea. Albuminuria may occur; there may be 
polyuria or sugar may be found in the urine from irri- 
tation of the central nervous system. In some instances 
there is inability to void the urine, not infrequently 
due to the administration of opiates for the severe 
pain. 

The height of the fever, while generally indicating 
the intensity of the disease, does not always do so, as a 
serious and dangerous attack may be accompanied by 
but little fever. 

There is hardly any part of the body that may not 
show a complication from this disease. The most fre- 
quent complications are, perhaps, pleuritis, pericarditis, 
pneumonia and arthritis. Inflammations of the parotid 
glands and of the kidneys are not infrequent. Acute 
and permanent disturbances of the special senses, due 
to localized inflammations in different parts of the 
cerebrum, are not infrequent. 



212 DIAGNOSIS OF MENINGITIS 

The prognosis has varied enormously in different 
epidemics, said to be from 20 to 75 per cent. With 
the serum therapy offered by Flexner and his 
co-workers this mortality has been very greatly 
reduced. In young children the mortality is greater 
than in adults. Even when the symptoms apparently 
ameliorate, the prognosis should be guarded, as many 
times a dangerous exacerbation occurs. 

DIAGNOSIS 

As the success of treatment in this disease depends 
so much on an early and immediate diagnosis, and the 
diagnosis is many times so difficult except by expert 
methods, it is essential, in discussing the therapy of 
this disease, to insure that the diagnosis is correct. 
This whole subject has recently been very ably dis- 
cussed by Du Bois and Neal* of New York. These 
physicians, specializing in the clinical and laboratorial 
findings in this disease, are able to present valuable 
statistics. They have examined 992 cerebrospinal 
fluids, and state that the conditions to be differentiated 
from meningococcic meningitis are streptococcic and 
pneumococcic meningitis, that due to the Streptococcus 
mucosus capsnlatus, influenza, tuberculous meningitis, 
poliomyelitis and meningismus, particularly when it 
occurs in pneumonia. 

There is always a leukocytosis in this disease, rang- 
ing from 25,000 to 40,000 per cubic millimeter. This 
leukocytosis is found early, and persists during the 
activity of the disease. Hess^ of Chicago found that 
the relative numbers of neutrophils and lymphocytes 
varied from time to time in this disease. He found 
that the eosinophils disappeared early in the infection 
and did not recur until convalescence was established. 
As sporadic cerebrospinal meningitis cases are often 



4. Du Bois, Phebe L., and Neal, Josephine B.: Summary of Four 
Years of Clinical and Bacteriologic Experience with Meningitis in New 
York City, Am. Jour. Dis. Child., January, 1915, p. 1. 

5. Hess, Julius H. : Leukocyte Counts in Pneumonia and Cerebrospinal 
Meningitis, Am. Jour. Dis. Child., January, 1914, p. 1. 



MENINGISMUS 213 

difficult to diagnose, and they many times simulate 
typhoid fever, besides the absence of a Widal reaction, 
a leukocytosis would preclude typhoid fever. Also, 
leukocytosis is not present in intermittent fever, and 
quinin should not be administered in meningitis ; hence, 
an examination of the blood, by showing absence of 
malarial plasmodia and the presence of a leukocytosis 
would show the disease not to be malarial fever. 

Meningismus is a condition now recognized as 
occurring not infrequently in serious illnesses, espe- 
cially in children. It is most frequently seen in pneu- 
monia, gastro-enteritis, and typhoid fever. While the 
cerebrospinal pressure may be increased in this con- 
dition, there may be no germ invasion, and no real 
inflammation, and though many meningeal symptoms 
may be present, they may all rapidly improve. The 
subject of meningismus is also discussed by Du Bois 
and Neal.* 

Du Bois^ states that the rigidity of the neck of 
infants in epidemic cerebrospinal meningitis is many 
times so easily overcome as to make one doubt its 
existence, but when the infant is turned on its side, the 
head is seen to be markedly retracted. Du Bois and 
Neal consider that the most important signs of menin- 
gitis are stiffness of the neck, variations of regularity 
in the rate and depth of respiration and MacE wen's 
and Brudzinski's signs. "MacEwen's sign is that 
which shows a change in the percussion note over the 
lateral ventricles due to increased intraventricular 
pressure;" while "Brudzinski's sign consists in the 
flexion and eversion of the legs and arms when an 
attempt is made to flex the head on the chest." Irregu- 
larities of the pupils, conjunctivitis, strabismus and 
nystagmus are all important signs of meningitis. Very 
young infants may show a bulging fontanel. Con- 
junctivitis is common in epidemic cerebrospinal menin- 

6. Du Bois, Phebe L. : Differential Diagnosis and Treatment of Epi- 
demic Cerebrospinal Meningitis, The Journal A. M. A., March 15, 
1913, p. 820. 



214 ERUPTION IN MENINGITIS 

gitis, but these investigators find that it is rare in other 
meningeal conditions. Ptosis of the eyelids and stra- 
bismus they find more common in tuberculous menin- 
gitis. The so-called Biot's breathing, that is, markedly 
irregular respirations, both in depth and time, they 
find present in true meningitis. Cheyne-Stokes respi- 
ration is more frequent in tuberculous meningitis, and 
the pulse is more likely to be irregular in rate and 
volume in this than in other meningeal conditions. 
Paralysis they find infrequent in epidemic cerebro- 
spinal meningitis, frequent but transitory in tubercu- 
lous meningitis, and always present in real polio- 
myelitis. The temperature is irregular in cerebrospinal 
meningitis; generally low in tuberculous meningitis; 
has a high rise and drops quickly in poliomyelitis. 

The petechial eruption of so-called spotted fever 
they found to occur but infrequently, they having 
found it only sixteen times in 112 cases. On the other 
hand, herpes is frequent. 

N. P. Barnes'^ of Washington states that he has fre- 
quently found, in true cerebrospinal meningitis, that a 
rash could be caused by directing an electric light and 
reflector on any portion of the body. He has found 
this sign absent in other forms of meningitis. He also 
calls attention to the fact that he has noted dilatation 
of the pupils produced in all his cases when Kemig's 
sign was being elicited. Kernig's sign alone was found 
by Du Bois and Neal not to be important in young 
children. 

Conner and Stillman^ of New York made a study of 
the respiratory irregularities of meningitis, and espe- 
cially of Biot's "meningitic rhythm," which rhythm 
lacks the regular alternation periods seen in the 
Cheyne-Stokes type of respiration. These investi- 
gators found that Cheyne-Stokes breathing occurred 

7. Barnes, N, P.: Interstate Med. Jour., 1913, xx, 9. 

8. Conner, Lewis A., and Stillman, Ralph G. : A Pneumographic 
Study of Respiratory Irregularities in Meningitis, Arch. Int Med., 
February, 1912, p. 203. 



SPINAL PUNCTURE 215 

in 53 per cent, of all cases of meningitis, and in 63 
per cent, of all cases in children, and it was much 
more frequent in tuberculous meningitis. They found 
that "Biot's breathing, when it occurs, may be 
regarded as almost pathognomonic of meningitis," 
while the Cheyne-Stokes type they found to be 
of no special diagnostic value in adults, but in children, 
if associated with other suggestive symptoms, it points 
decidedly toward meningitis. 

Of course the most important diagnostic determina- 
tion is made by spinal puncture. It may be well first 
to note that Dixon and Halliburton^ have recently 
investigated cerebrospinal pressure. After hemorrhage 
they find a fall in this pressure. They found that vari- 
ations in cerebrospinal pressure alter the cerebro- 
venous pressure. They experimented also with vari- 
ous drugs, and found that suprarenal pressor substance 
affected the cerebrospinal fluid only indirectly, and 
that the cerebrospinal pressure falls more rapidly than 
the blood pressure. There is a rise in spinal pressure 
after the administration of amyl nitrite. They found 
that deficiency in oxygen or an increase in carbon 
dioxid in the blood raised the cerebrospinal pressure. 
In other words, they concluded that there may be con- 
stant variations in the amount of the cerebrospinal 
fluid and consequently the cerebrospinal pressure, due 
to different conditions of the circulation, but that the 
amount of change was insignificant compared with 
that caused by secretory activity of the walls of the 
cerebrospinal canal. 

The Lange gold chlorid reaction of the cerebrospinal 
fluid of infants and young children as giving evidence 
of cerebrospinal disease, and especially of syphilis, has 
been recently tried in over sixty children, by Grulee 
and Moody^^ of Chicago, who give their technic, but 

9, Dixon and Halliburton: Jour. Physiol., 1914, xlviii, 128. 
10. Grulee, C. G., and Moody, A. M.: The Lange Gold Chlorid Reac- 
tion on the Cerebrospinal Fluid of Infants and Young Children, Am. 
Jour. Dis. Child., January, 1915, p. 17. 



216 PREVENTION OF MENINGITIS 

from their findings come to the conclusion that the 
test is only an aid in diagnosis. 

In spinal puncture Du Bois and Neal find that *'a 
clear fluid increased in amount indicates usually one 
of the following conditions : tuberculous meningitis, 
poliomyelitis, syphilitic involvement of the central 
nervous system, brain tumor, or meningismus. A 
cloudy fluid is the result of a meningitis due to the 
meningococcus or some of the other pyogenic organ- 
isms." As above suggested, in meningismus there is 
increased cerebrospinal fluid, but it is normal in char- 
acter. The amount of fluid withdrawn by Du Bois 
and Neal has varied greatly; they have withdrawn as 
much as 100 c.c. "In a true meningitis the fluid is 
inflammatory in character — of the nature of an exu- 
date, and shows an increase in albumin and globulin, 
and in the number of cells." In meningismus they 
consider the increased fluid as a transudate. With a 
cloudy fluid and the finding of the meningococcus, the 
diagnosis of so-called cerebrospinal fever is positive. 

PREVENTION 

In the first place, it may be mentioned that rarely 
it has been noted that the disease has attacked an 
individual more than once. In the second place, 
carriers have become more or less immune, but it is 
self-evident that, having been discovered, although 
close contact is needed, and though the germ is not 
sturdy and is readily killed after leaving the body, they 
must be isolated and treated. Therefore, the persons 
immediately surrounding a case of meningococcic men- 
ingitis should have the secretions of the nose and naso- 
pharynx examined for this germ. It has not been 
shown just what local treatment of the nose and throat 
of these individuals is advisable, but antiseptic sprays, 
swabbings and gargles are certainly indicated. 

Vaccinations, with dead meningococci, of children 
who have been directly exposed to the disease, and of 
the nurse or other persons, who must care for cerebro- 



TREATMENT OF MENINGITIS 217 

spinal fever patients would seem to be advisable in 
preventing the spread of the disease. It has been 
suggested that a moderate amount of immunity would 
be sufficient to prevent this particular infection. How 
long immunity would last is not known. Vaccination 
with this germ causes a febrile reaction, with leukocy- 
tosis. Meningococcus vaccines are now prepared, and 
can be readily obtained. Sophian and Black^^ have 
discussed this subject. Meningococcic vaccine has 
been injected, and antimeningococcic serum has been 
sprayed into the noses and throats of carriers, with 
some success. It has not been shown how constantly 
this treatment is successful. 

TREATMENT 

It is hardly necessary to urge that the disease should 
be made reportable, and be reported as soon as the 
diagnosis is positive. A patient with 2Lny primary men- 
ingitis should be more or less isolated until the germ 
of infection has been determined. 

Flexner has given us a specific treatment, and the 
method to be followed in its administration cannot be 
better described than by once more referring to 
Du Bois and Neal. 

If the fluid taken from the spinal canal is cloudy, 
they immediately inject antimeningitis serum, warmed 
to the body temperature, and injected slowly. They 
consider a syringe as dangerous, and adopt Koplik's 
gravity method. They state, in general, that the dose 
for an adult is from 20 to 40 c.c, and for infants and 
children from 3 to 20 c.c, the amount largely depend- 
ing on the quantity of fluid withdrawn, and the dose 
should usually be from 5 to 10 c.c. less than the amount 
of fluid withdrawn. They state that occasionally in 
true meningococcic meningitis they have obtained no 
fluid from the canal in spinal puncture, so-called dry 

11. Sophian, Abraham, and Black, J.: Prophylactic Vaccination 
Against Epidemic Meningitis, The Journal A. M. A., Aug. 17, 1912, 
p. 527. 



218 SERUM IN MENINGITIS 

tap. In such cases they have injected a small amount 
of the antiserum, with careful watching of the patient 
to note changes in pressure as determined by the char- 
acter of the pulse and respiration. In severe cases 
they inject the antiserum every twelve hours until there 
is improvement. In moderate and mild cases they 
usually repeat the injection once a day for four days. 
The bacteriologic findings of the fluid withdrawn at 
the last injection, and the condition of the patient, 
determines whether the antiserum should be given 
longer. They state that usually from four to six 
injections are necessary, but they have given sixteen 
or more. On successive punctures and injections the 
patient is turned first on one side and then on the 
other, which they think insures the emptying of the 
lateral ventricles in rotation. In other words, a patient 
who lies on his right side for one puncture will be 
placed on his left for the next. 

A number of times they have seen the patient go 
immediately into a condition of shock after the injec- 
tion of the serum, with the respiration shallow, the 
face pale, and the pulse rapid and thready. They 
have never, however, seen a patient die in this con- 
dition, and if the needle is still in place they withdraw 
some of the serum. Artificial respiration is resorted 
to if the breathing has ceased, and hypodermic stimu- 
lation of the heart is given. This condition of shock 
does not occur frequently with the smaller doses that 
are now administered. The serum they have lately 
used contains 0.2 per cent, of trikresol, and as they 
have used trikresol serum over five hundred times in 
patients of all ages, they do not believe that fatalities 
are due to the phenol contained. However, on account 
of objection having been made to trikresol, they are 
ready to try chloroform as a preservative. 

Barnes^^ states that antimeningococcus serum diflrers 
from ordinary antiserums in that it is destructive to 

12. Barnes: Interstate Med. Jour., 1913, xx, No, 9. 



GENERAL MEASURES IN MENINGITIS 219 

the meningococci, and at the same time neutralizes the 
endotoxins set free during the destruction of the 
germs. 

If a case of cerebrospinal fever shows a tendency to 
become chronic, Du Bois and Neal make an autogenous 
vaccine and give it every four or five days, "in doses 
of from 250 to 1,000 million" bacteria. They are not 
convinced of the value of this treatment, but they have 
not seen it do any harm. 

The general treatment of cerebrospinal fever 
demands the best hygienic surroundings obtainable, 
and a quiet, cool, darkened room, as in any meningitis. 
The bowels should be thoroughly moved in the begin- 
ning, and then, daily, or every other day, the patient 
should receive a laxative, if needed. 

As the vomiting is reflex, stomach sedatives are of 
no avail. As the central condition is improved or the 
patient becomes more stupid, the vomiting will cease. 
Food in the early stages should not be pushed, as there 
is great repugnance to it. Plenty of water, and later 
simple cereal gruels and milk should be the early diet. 
The subsequent diet should depend on the height of 
the fever and the ability of the patient to digest. In 
the stage of convalescence food should be pushed, if it 
is well digested. Through the acute illness, starches 
should be given to prevent acidemia. If the pain is 
sufficient to require sedatives, much food should not 
be given, as it will not well digest. 

A most important symptom of this disease is likely 
to be pain, and there is no excuse for allowing a 
patient, because it is a young child, to suffer pain. 
Morphin or codein represent the most efficient and the 
safest drugs, the dose, of course, being regulated 
according to the age of the patient and the effect. 
Generally it is better to administer a very small dose 
hypodermically than a large dose by the mouth; the 
action of the whole dose is obtained, and there is no 
doubt as to whether or not it is absorbed. Ergot given 



220 PAINFUL JOINTS IN MENINGITIS 

in aseptic form, intramuscularly, not only seems to act 
as a sedative to the nervous system and possibly dimin- 
ishes congestion, but it certainly prolongs the action of 
any dose of a narcotic. Less morphin, codein or other 
narcotic will be required to stop pain and cause rest if 
ergot is coincidently given. If the blood pressure is 
low, this is another indication for the administration 
of ergot. Generally, if the blood pressure is high, 
ergot should not be given. 

Local applications of cold and ice to the head (the 
hair being cut short) and to the spine, may inhibit the 
inflammation, and sometimes seem to be of great value. 
At other times these cold applications seem to increase 
the pain. This seems to be especially true if the tem- 
perature is low. Exactly what these cold applications 
do to the blood vessels of the parts inflamed is a ques- 
tion that has not been determined. Cold sponging of 
the body is hardly advisable, as it tends to increase 
the internal congestion. Theoretically, it would seem 
more sensible, and practically it is often better to use 
hot applications, as hot sponging, and even hot baths 
have been advised, for very young children, to relieve 
the congestion of the central nervous system. 

Painful joints may be wrapped in cotton and kept 
warm, much as is done in rheumatism. Conjunctivitis 
should be treated with a simple boric acid wash. The 
throat and nose should be cleansed with simple saline 
sprays or mild antiseptic gargles. 

There would seem to be no excuse for the adminis- 
tration of quinin, strychnin, caffein, or any other cere- 
bral stimulant. It would also seem inadvisable to 
administer alcohol in any form. If the blood pressure 
is high, hot sponging, small doses of nitroglycerin and 
more brisk catharsis are indicated. 

The patient should remain in bed for at least a week 
after the cessation of the fever, and convalescence 
should be slow, and the return to activity should be 
delayed. During convalescence it is well to administer 



INFLUENZAL MENINGITIS 221 

small doses of sodium iodid, as iodid seems to be effi- 
cient in aiding the absorption of exudates. Iron and 
other tonics may be indicated. 

Stiffening of the muscles and joints may require 
massage, and, if there are any adhesions in the joints, 
the orthopedist should be consulted as to whether pas- 
sive movements or forcible breaking up of these adhe- 
sions under an anesthetic is advisable. 

The frequency with which mental deterioration 
occurs can only be determined by a long careful study 
of many cases. Cerebral degenerations and disturb- 
ances may develop after many years and yet appar- 
ently have been caused by this disease. 

The various complications that may occur have 
already been mentioned, and their treatment would be 
that usual for the localized inflammation modified by 
the general condition of the patient from the cerebro- 
spinal fever. 

INFLUENZAL MENINGITIS 

That the Bacillus influenzae can cause meningitis 
has long been known. It has been well described by 
Rhea^^ of Montreal. The serum treatment of influ- 
enzal meningitis was presented by WoUstein.^* Dr. 
Flexner has produced an anti-influenzal serum which 
may now be used in this disease. The success of such 
treatment has not yet been determined. 

A brief but careful review of recent literature up 
to about a year ago, on meningitis other than that of 
cerebrospinal fever, has been presented by Heiman 
and Feldstein.^^ . 



13. Rhea, Lawrence J.: Cerebrospinal Meningitis Due to Bacillus 
Influenzae, Arch. Int. Med., August, 1911, p. 133. 

14. Wollstein: Jour. Exper. Med., 1911, xiv, 73. 

15. Heiman, Henry, and Feldstein, Samuel: Resume of the Recent 
Literature on Meningitis (not Including Meningococcus Meningitis), 
Am. Jour. Dis. Child., September, 1913, p. 199. 



ACUTE ANTERIOR POLIOMYELITIS 
(INFANTILE PARALYSIS) 

It was not definitely shown, until 1909, that this 
disease belonged to the infections and was contagious, 
although it had been long suspected. More or less 
isolated instances and some slight group attacks had 
occurred in America for many years, but we have 
had epidemics only since 1907, caused probably by 
importations of the germ from Europe, where it has 
been long endemic. In 1909, Landsteiner and Popper 
reported that they had caused infantile paralysis in 
monkeys by inoculating them with a spinal cord emul- 
sion obtained from a child who died from this dis- 
ease. Noguchi and Flexner later reported that they 
had been able to cultivate a causative organism of this 
disease. Recently, Flexner and his co-workers^ have 
shown that the contagium is contained in the secre- 
tions of the nose, and that undoubtedly there are car- 
riers of this disease. It seems to be demonstrated 
that the infection or poison reaches the nervous sys- 
tem through the lymph, but probably reaches its point 
of activity, namely, the spinal cord, by means of 
the cerebrospinal fluid. In previous experiments 
Flexner and Amoss^ have shown that in all proba- 
bility infection does not reach the individual from the 
bites of insects, as they were unable to infect monkeys 
by directly introducing the virus into the blood. This 
does not preclude the possibility of domestic animals 
like cats and dogs carrying the contagium and caus- 
ing infection by way of the nostrils and lymph chan- 
nels. It has not been shown that flies transmit the 
contagium, nor that the association with stables has 

1. Flexner, Simon, and Amoss, Harold L. : Localization of the Virus 
and Pathogenesis of Epidemic Poliomyelitis, Jour. Exper. Med., Sept. 1, 
1914, p. 2'i9; abstr.. The Journal A. M. A., Sept. 26, 1914, p. 1136. 

2. Flexner, S., and Amoss, H. L. : Penetration of Virus of Polio- 
myelitis from Blood into Cerebrospinal Fluid, Jour, Exper. Med., April, 
1914, p. 411; abstr., The Journal A. M. A., April 25, 1914, p. 1360. 



ETIOLOGY OF ANTERIOR POLIOMYELITIS 223 

increased the liability of infection, as has been sug- 
gested. It does not seem frequent that more than one 
person in the same household is affected, although 
such cases occur. However, in epidemics the majority 
of patients are likely to come from the same general 
region. 

Fraser^ of New York reports his observations on 
ninety cases of epidemic poliomyelitis. He found that 
the age varied from 9 months to 14 years. The 
majority of cases, especially when it is sporadic, has 
always occurred in young children under 5 years of 
age. The death rate is generally low, varying from 
4 to 16 per cent., but the paralyses resulting are con- 
stant and frequent. 

A review of the etiology, bacteriology and pathol- 
ogy of this disease is given by Sever* of Boston. 
Flexner and Lewis' splendid work on this subject is 
reported in various numbers of The Journal.^ They 
state that the infecting agent in this disease belongs 
to the class of minute filterable viruses which cannot 
be demonstrated with certainty by means of the micro- 
scope. They also showed that spinal fluid withdrawn 
on the third day of the infection, before the appear- 
ance of paralysis, contains the virus which will cause 
infections of monkeys. Flexner, Noguchi and 
Amoss^ have recently again shown that the minute 
micro-organism isolated from poliomyelitic tissue is 
probably an etiologic factor, if not the cause, of epi- 
demic poliomyelitis. Flexner and Lewis^ also showed 
that the disease can be transmitted from monkey to 

3. Fraser: Am. Jour. Med. Sc, July, 1914, p. 1. 

4. Sever: Interstate Med. Jour., 1914, p. 705. 

5. Flexner, Simon, and Lewis, Paul A.: The Transmission of Acute 
Poliomyelitis to Monkeys, The Journal A. M. A., Nov. 13, 1909, 
p. 1639; The Nature of the Virus of Epidemic Poliomyelitis, ibid., 
Dec. 18, 1909, p. 2095; Experimental Epidemic Poliomyelitis in Monkeys, 
ibid., April 2, 1910, p. 1140; Experimental Poliomyelitis in Monkeys, 
ibid., May 28, 1910, p. 1780. 

6. Flexner, Simon; Noguchi, Hideyo, and Amoss, Harold L.: Con- 
cerning Survival and Virulence of the Microorganism Cultivated from 
Poliomyelitis Tissues, Jour. Exper. Med., January, 1915, p. 91. 

7. Flexner, Simon, and Lewis, Paul A.: Epidemic Poliomyelitis in 
Monkeys, The Activity of the Virus, The Journal A. M. A., Jan. 1, 
1910, p. 45. 



224 PREVENTION OF ANTERIOR POLIOMYELITIS 

monkey. They further showed that the germ or virus 
resists freezing, and therefore the disease is not 
stopped by cold weather. They also believe that one 
attack confers immunity. 

Lucas^ found that monkeys after inoculation 
showed a lymphocytosis during the acute stages, but 
a marked and constant leukopenia. The blood at this 
time also showed an eosinophilia. This disturbance in 
the white blood count disappeared when the acute 
stage was over. 

PREVENTION 

It is quite probable that the so-called "distemper" 
which at times attacks dogs and may attack horses, is 
really caused by this same infection. Hence, a dog 
affected with distemper should be isolated, and no 
child should be allowed to associate with it. While 
it has not been shown that flies will carry this disease, 
in all probability they may transmit the infection by 
their feet. Consequently, flies should be excluded by 
proper screens, if possible, from any animal that suf- 
fers from distemper, and certainly should be pre- 
vented from reaching an individual sick v/ith polio- 
myelitis. 

As early as Feb. 12, 1910, Flexner and Lewis® 
showed that this disease was contagious by means of 
the secretions of the mucous membrane of the nose 
especially, and also of the throat, and therefore that 
every patient should be isolated, and that the disease 
should be made reportable to the boards of health. 

The nurse and the family should understand that 
the same care must be exercised in destroying the 
contagium and preventing the contamination of arti- 
cles and substances by the secretions of the nose and 

8. Lucas: Tr. Mass. Med. Soc, June, 1910; the subject is also dis- 
cussed by Gay, Frederick P., and Lucas, William P.: Anterior Polio- 
myelitis. Methods of Diagnosis from Spinal Fluid and Blood from 
Monkeys and in Human Beings, Arch. Int. Med., September, 1910, 
p. 330. 

9. Flexner, Simon, and Lewis, Paul A.: Epidemic Poliomyelitis in 
Monkeys. A Mode of Spontaneous Infection, The Journal A. M. A., 
Feb. 12, 1910, p. 535. 



SYMPTOMS OF ANTERIOR POLIOMYELITIS 225 

throat of a poliomyelitis patient as is so well under- 
stood must be taken in diphtheria. 

As soon as a case is reported to the board of health, 
the school board should be informed (as such cases 
are frequently in children too young to go to school) 
that they may send home from school the other chil- 
dren of the family, and if there is an epidemic, per- 
haps the other children of that tenement. The incu- 
bation period is said to vary, and may be as long as 
ten days, but to be safe from causing infection in 
others, such children should remain out of school for 
two weeks. 

EARLY SYMPTOMS 

Although a patient who is old enough may com- 
plain of headache and pains, especially in the epi- 
demic form of the disease, still, in this as well as in 
the sporadic form, the onset may be so rapid that a 
child well the night before may be found with high 
fever and even with paralysis in the morning. Pain 
is referred generally to the muscles of the back and 
legs, and later to the muscles of the arms. The tem- 
perature in serious cases may be high, but the ordinary 
range of rectal temperature was found by Fraser to 
be from 101 to 103. The pulse-rate is high, and is 
generally over 120. While pain may keep the lit- 
tle patient awake, and there may be a great amount 
of irritability and restlessness, drowsiness and heavi- 
ness was noted by Fraser in half of his cases, 
although there were often twitchings and jerkings 
during sleep. In two-thirds of his cases he found 
stiffness of the neck and back, which is so character- 
istic of cerebrospinal meningitis. The greatest tender- 
ness is found generally in the extremities. Although 
this might last but one or two days, it sometimes per- 
sists for three or four weeks. The tendon reflexes are 
found generally absent. 

Although, as just stated, paralysis may occur 
almost coincident with the illness in sporadic cases, 
in epidemic cases paralysis seems to develop most f re- 



226 TREATMENT OF ANTERIOR POLIOMYELITIS 

quently on the third or fourth day. The acute illness 
lasts from one week to ten days. A large number 
of Fraser's cases showed some slight facial paralysis. 
If the respiratory muscles were affected, the prognosis 
was dire. There may be paralytic interference with 
urination, and defecation may be difficult from inabil- 
ity of the abdominal muscles to act. 

It should be remembered that many abortive forms 
of this disease probably occur without any paralysis, 
and many times without a diagnosis, and such cases 
may doubtless spread infection. Koplik,^° in reviewing 
an epidemic of 1,200 cases, states that many atypical 
forms occur. 

As to the extremities, one or both arms may be 
paralyzed, or one arm and one leg, or both legs, or 
there may be crossed arm and leg paralysis. The arm 
paralysis is not often complete, and the recovery is 
more rapid. Complete loss of response to faradism 
means a bad prognosis as to recovery, and atrophy 
will rapidly occur. If response to faradism is not 
completely lost, the outlook, with proper care and 
treatment, is good. The rapidity of recovery from 
paralysis, and the number that completely recover vary 
with the different epidemics ; but the number that 
completely recover is lamentably sm.all. More scien- 
tific treatment by nerve and orthopedic experts will 
doubtless make this percentage of complete recover- 
ies much greater. 

TREATMENT 

A. The Acute Stage. — The same care in isolation, 
and of the secretions of the nose and throat, to pre- 
vent possible infection of others or contamination of 
articles, should be carried out as has been described 
for the other infectious diseases. Flies and all domes- 
tic animals must positively be excluded from the sick- 
room. As soon as the diagnosis is positive, the dis- 
ease should be reported to the board of health, 

10. Koplik, H. : An Epidemic of Acute Poliomyelitis, Arch. Pediat., 
May, 1909, p. 321. 



TRANSMISSION OF ANTERIOR POLIOMYELITIS 227 

whether or not it is a reportable disease in the com- 
munity. 

Flexner" has shown that bedbugs may become 
infected with this disease. Whether or not they can 
transmit the disease to a human being by their bites 
has not been shown. Mosquitoes and lice have not yet 
been shown to be guilty of carrying the infection, but 
they, as well as bedbugs and fleas, are not needed in 
the treatment of this disease. 

As Flexner states that the virus is eliminated by the 
intestines as well as by the nose and throat, all move- 
ments of the bowels during the course of the disease, 
and perhaps for some little time after the acute stage 
is over, should be as thoroughly disinfected as they 
are in typhoid fever. Lucas and Osgood^^ found the 
virus in the nasal secretions of a human being four 
months after the acute stage of an attack of poliomye- 
litis. They also found the virus in the nasopharynx 
of persons who were in attendance on a patient ill with 
the disease, and in the nasopharynx of a patient who 
had had the disease 204 days after the acute infection. 
Kling,^^ however, thinks that the virus soon loses its 
virulence, and that quarantine need not be continued 
for more than two weeks. It cannot yet be decided 
just how long quarantine should be continued, but 
two weeks should be the under limit, and better, three 
weeks. That more of the attendants or associates of 
a patient sick with poliomyelitis do not contract, the 
disease may be because they are insusceptible, or they 
may have become immune from some previous abor- 
tive attack. 

There has not yet been produced an antiserum, 
although it is most sincerely hoped that Flexner and 
his co-workers will be able to add such a serum to 



11. Flexner, Limon: The Mode of Infection in Epidemic Poliomyelitis, 
The Journal A. M. A., Oct. 12, 1912, p. 1371. 

12. Lucas, William P., and Osgood, Robert B.: Transmission Experi- 
ments with the Virus of Poliomyelitis, The Journal A. M. A., May 24, 
1913, p. 1611. 

13. Kling, Carl: The Etiology of Epidemic Poliomyelitis, Wien. klin. 
Wchnschr., Jan. 10, 1913, p. 41. 



228 MEDICATION IN ANTERIOR POLIOMYELITIS 

the list of their splendid achievements. With our 
better knowledge of the action of hexamethylenamin, 
we cannot expect germicidal activity in the cerebro- 
spinal fluid, which is alkaline. It has been shown 
that this drug has no germicidal activities, except in 
an acid medium, and, therefore, it is of special value 
only in infections of the pelvis of the kidney, ureters, 
bladder and urethra, and then only when the urine 
is acid. Hence, when the disease has started, there is 
no known medical method of aborting it, although 
mild infections may abort without paralysis. 

The treatment in this stage of the disease is to 
relieve cerebral and spinal congestion and remove all 
possible toxins that may be absorbed from the intes- 
tinal canal by free but gentle catharsis. Calomel, in 
one sufficient dose, associated with cascara, aloin or 
rhubarb, as deemed advisable, is always a good method 
of treatment. Castor oil is another, or at times a 
quickly acting saline cathartic may be advisable. Sub- 
sequently the bowels should be moved as frequently 
as the diet and the condition of the intestines seem to 
require. A child that is not taking much food for the 
first two or three days after the first cleaning out of 
the intestines need not necessarily be bothered with a 
laxative every day during this first stage of the dis- 
ease. As soon as paralysis begins, it may be difficult 
to cause the bowels to move, and a simple glycerin 
suppository or a small enema may be needed. 
' The child must not be allowed to forget to urinate, 
as some loss of normal bladder irritability may allow 
urine to be retained and distention of the bladder to 
occur. Therefore, the child should be encouraged to 
urinate at about four-hour intervals. Of course, if 
the urine cannot be passed, it must be drawn. 

Generally the fever is not high. If it is high, two or 
three small doses of acetanilid may be administered; 
or sponging the body with warm water is advisable. 
General cold sponging or general cold applications are 
inadvisable, as tending to cause increased congestion 



PAIN IN ANTERIOR POLIOMYELITIS 229 

of the central nervous system. The value of an ice 
cap as a reducer of temperature is doubtful, and it is 
likely to cause the child to become more restless. The 
value of a spinal ice bag is also doubtful, as many 
times these cold applications cause an increase of pain. 

Pain must be stopped in a child as well as in an 
adult; this fact is often forgotten. The physician 
allows a child to suffer because he dislikes to give 
strong narcotics, w^hen an adult would demand some- 
thing to stop his pain. If there is high fever and a 
few doses of acetanilid have been given, this may pre- 
vent some of the pain, but pain is most safely com- 
bated by small doses of morphin, codein, or opium in 
some form. Perhaps there is no better method of 
giving this narcotic drug to a child than by means of 
the deodorized tincture of opium. The dose may be, 
even to a young child, one drop every hour until the 
child is sleeping or is quiet. If the child is very 
young, of course the dose should be less, and for a 
child 10 years of age the dose should be larger. If the 
brain is so affected that the child is stupid, pain is not 
much felt, and narcotics will not be needed. Unless 
the child is excessively nervous, restless, sleepless, and 
twitching and jerking about the bed, such cerebro- 
spinal depressants as chloral and bromid are not indi- 
cated, as one can but feel they might tend to increase 
the muscle debility and paralysis that must follow the 
acute stage of the disease. It seems safer and more 
rational to give for this condition opium or one of its 
alkaloids in a dose sufficient to cause quiet and rest. 

In this disease, as in all forms of meningitis, the 
bedroom should be quiet and removed as far as possi- 
ble from all noise and disturbance. The child should 
not be unnecessarily spoken to, and there should be 
frequent darkening of the room in order that the 
patient may get all the rest possible. 

During the active stage food should not be pushed. 
Part of the diet should be milk, and the rest of it 
should be cereal gruels. The diet should not be 



230 LOCAL TREATMENT 

wholly milk, for in this as in all acute diseases the 
possibility of acidemic conditions occurring should not 
be forgotten, and starches should always be given in 
the form most acceptable to the patient. The first 
day or two the child will be thirsty, and should be 
allowed all the water it desires. As soon as the fever 
diminishes or ceases, nutrition should be pushed, and 
the child should be encouraged to eat so that the gen- 
eral strength may be recovered as rapidly as possible. 
If at this time the tongue is coated, the digestion poor 
and the appetite insufficient, it may be because gastric 
acidity is insufficient, and a few drops (not more than 
five) of dilute hydrochloric acid, in water, after meals, 
may aid in overcoming these conditions. Or perhaps 
still better is the tincture of iron chlorid in a dose of 
not more than three or four drops, in a little fresh 
lemonade or orangeade. 

B. Local Treatment. — Fixation of the painful 
extremities and of the back, in the most restful posi- 
tion, with the aid of cushions and pillows, is important 
during the acute stage. As there is no special inflam- 
mation in any joint or muscle, cold or ice to a painful 
region is not indicated. Dry warmth may cause a 
lessening of the pain and is often of value. If the 
limbs affected become cold from disturbed circulation, 
they should be surrounded with cotton or covered 
with flannel. Restriction by bandages is inadvisable. 

The pathologic lesions of the disease may be studied 
in an article by Flexner, Clark and Amoss.^* 
Several years ago Lovett and Lucas^^ studied 635 
cases of infantile paralysis, and came to the conclu- 
sion that paralysis of one leg was nearly four times 
more frequent than paralysis of both legs, and paraly- 
sis of an arm and leg of one side was more common 
than was a crossed paralysis. The internal muscles 

14. Flexner, S., Clark, P. F., and Amoss, L.: Epidemiology of Polio- 
myelitis, Jour. Exper. Med., Feb. 1, 1914. 

15. Lovett, Robert W., and Lucas, W. P.: Infantile Paralysis. A 
Study of 635 Cases with Especial Reference to Treatment, The Journal 
A. M. A., Nov. 14, 1908, p. 1677. 



PAR.\LYSIS IN ANTERIOR POLIOMYELITIS 231 

of an extremity were more frequently affected than 
the external, and the anterior than the posterior. The 
most common muscle to be affected in the leg they 
found to be the quadriceps ; the next in frequency was 
the tibialis anticus and anterior muscles of the lower 
leg. If the hamstring muscles were affected it was 
more often the internal than the external, and the 
sartorius muscle they found frequently not to be 
affected even when the quadriceps was. They found 
the internal rotators of the thigh more frequently 
affected than the external rotators, and the adductors 
more frequently than the abductors. The short toe 
flexors they found the least likely to be affected. In 
the upper extremity, the arm is more frequently 
affected than the forearm, and the deltoid the muscle 
most affected, although the biceps, triceps and scapu- 
lar muscles may also be affected. 

During the first stages of the paralysis great care 
must be taken in watching the position of the limbs, 
especially the legs, to prevent contractions caused by 
the pulling of the unaffected muscles. Massage is 
soon valuable, but must be very gentle. Proper mas- 
sage will not only increase the nutrition of the affected 
muscles, but cause relaxation of spasm of the unaf- 
fected muscles. It may be necessary to devise some 
apparatus to keep the leg or foot from becoming 
deformed. For this purpose various splints, or 
wooden or wire troughs properly padded with cotton 
may be used. Gibney and Wallace^^ urge that the 
legs should be kept straight or in slight flexion at the 
knees and in line with the body, while the feet should 
be kept at right angles with the legs. 

The value of having the child, as early as possible, 
make slight voluntary efforts with the paralyzed mus- 
cles is excessively important. All neurologists and 
orthopedists now believe that one voluntary contrac- 
tion of a muscle is of very much greater value than 

16. Gibney, V. P., and Wallace, Charlton: The Recent Epidemic of 
Poliomyelitis, The Journal A. M. A,, Dec. 21, 1907, p. 2082. 



232 TREATMENT OF PARALYSIS 

many passive activities of a muscle or contractions 
caused by electricity or other irritant. 

Some writers believe that counterirritants applied 
to the spine, such as cautery treatments, are of value 
in hastening the stage of resolution of this disease. 
While they may be of value, consideration must 
always be given to the disturbance that it will cause 
the child who has suffered enough pain, and who 
already has difHculty in finding comfortable positions 
in bed. 

C. Paralysis. — When the circulation is poor in an 
extremity, the local application of heat in any form, 
and perhaps by baking, is of value. As soon as it is 
believed that all active inflammation in the spinal cord 
has ceased, electricity should be begun, and Jones^' 
believes that electricity should not be used until from 
three to eight weeks from the beginning of the infec- 
tion. Galvanism should then be used on the nerve 
trunks, gently and not too strong, while the muscles 
are caused to contract by f aradism as long as they react 
to that current. If they do not react to the faradic 
current, the galvanic current should be used to cause 
contraction by making and breaking. The rapidity of 
the making and breaking galvanic current should not 
be too great, nor should any kind of muscle stimula- 
tion be continued too long at any one sitting; in fact, 
at first only a few contractions should be caused. 

Voluntary training directed by a skilled orthopedist, 
and the application of any splints or apparatus that 
may be necessary to prevent deformities and atrophies 
should soon be inaugurated, as Taylor^^ and many 
others believe that massage and electricity are very 
ineffective in causing recovery of muscles paralyzed 
by poliomyelitis. All physicians and surgeons urge 

17. Jones, R. : Infantile Paralysis (Acute Anterior Poliomyelitis). 
Its Early Treatment and Surgical Means for Alleviation of Deformities, 
Brit. Med. Jour., May 30, 1914; abstr., The Journal A. M. A., July 4, 
1914, p. 63. 

18. Taylor, H. L. : The Management of Poliomyelitis and Its Sequelae, 
Med. Rec, New York, Oct. 15, 1910; abstr.. The Journal A. M. A., 
Oct. 29, 1910, p. 1590. 



SURGICAL TREATMENT 233 

that the greatest improvement is caused by plenty of 
rest in bed, graded exercise, warm baths, good food 
and fresh air. In other words, the better the nutrition 
the greater the improvement in the paralyzed muscles. 
Muscles may even recover after a year or more of 
paralysis when treated by a skilled orthopedist. It 
should be emphasized that rough, harsh massage and 
misdirected use of electricity may do serious harm to 
the paralyzed and contracted muscles. In a word, the 
general practitioner should as quickly seek the aid of 
the orthopedist in treating the paralysis of this dis- 
ease as he would seek a skilled aurist in an internal or 
middle-ear inflammation. 

Surgical repair of deformities that cannot be cor- 
rected by apparatus or muscle training has now 
reached a stage never equaled before, and tendon 
transplantation and other orthopedic operative mea- 
sures cannot too soon be considered when improve- 
ment ceases to occur in a limb affected with paralysis 
from poliomyelitis. A recent discussion of this sub- 
ject is presented by Moore^^ of Philadelphia. 



19. Moore, J. W. : The Surgical Treatment of Infantile Paralysis, New 
York Med. Jour., Aug. 29, 1914, p. 404. 



INDEX TO SUBJECTS 



PAGE 

Acidosis, acute 10 

Adenitis 90 

in scarlet fever 199 

Adenoids 88 

Air 8 

chemical constituents of 69 

contamination 68 

impure 30 

Albuminuria in scarlet fever 199 

Alcohol, effect of, on children 67 

Asthma 110 

Autointoxication 10 

Bad habits of childhood 10 

Bathing 12 

Bronchitis, acute 108 

treatment of 109 

Carbon dioxid 36 

monoxid 35 

Carriers, diphtheria 144 

diphtheria, treatment of 146 

disease 21 

typhoid, treatment of 51 

Cerebrospinal Fever: see Meningitis, Cerebrospinal Epidemic. 

Chicken-pox 185 

prevention of 187 

Children: see Schoolchildren. 

Clothing in winter 26 

Colds 92 

aborting 98 

aconite in 100 

cleansing of nasopharynx in 102 

prevention of , . 93 

treatment of 99 

Colon bacillus 33 

Contagion, dissemination of 70 

prevention of 19 

Coryza, acute 94 

pathology of 95 

treatment of 96 

Cough in measles 179 

Coughs 104 

causes of 105 

types of . 106 

Defectives, marriage of 39 

Diphtheria 143 

active immunization in 151 

antitoxin treatment of 157 

carriers of 144 

carriers of, treatment of 146 

dissemination of 71 



236 INDEX 

Diphtheria (continued) PAGE 

gargles and throat washes in 161 

heart in, care of 164 

immunity in 148 

laryngeal 167 

nasal, treatment of 162 

paralysis following 167 

prophylaxis of, in schools 153 

raising of quarantine in. . 166 

Schick test in 149 

toxin-antitoxin injections in 150 

transmission of 143 

treatment of 155 

Disinfection 22 

of schools 76 

Dust 9, 28 

prevention 29 

prevention of diseases due to 32 

Eugenics 37 

Eyes of schoolchildren 65 

Feet, hygiene of 78 

Flies, dissemination of disease by 73 

Food and immunity to disease , 15 

Fumes and gases, noxious 30 

Fumigation of schools 11 

Gases and fumes, noxious 30 

Grip: see Influenza. 

Heart in diphtheria 164 

in scarlet fever 205 

Heat and infant mortality 6 

Hookworm disease 118 

treatment cf 120 

Hydrogen sulphid 36 

Hygiene, teaching of, to schoolchildren 60 

Immunity to disease caused by proper food 15 

Infant mortality and heat 6 

Infectious diseases, common 91 

Influenza 110 

complications of 113 

dissemination of 72 

treatment of , 114 

types of 112 

Intestinal putrefaction 34 

Isolation 21 

Malaria 74 

eradication of 74 

Marriage of defectives 39 

regulation of 38 

Measles 171 

blood in 174 

convalescence in 181 

cough in 179 

diet in 180 

dissemination of 72 

eruption in 175 



INDEX 237 

Measles (continued) page 

etiology of 172 

fever in 181 

German 183 

prevention of 176 

symptoms of 173 

transmission of 177 

treatment of 178 

Meat inspection 14 

Medical inspection of schoolchildren 62 

Medical inspector, few suggestions for 64 

Meningismus 213 

Meningitis, cerebrospinal, epidemic 209 

diagnosis of 212, 215 

eruption in 214 

etiology of 209 

influenzal 211 

painful joints in , 220 

prevention of 216 

spinal puncture in 215 

symptoms of 211 

treatment of 217 

Methane 35 

Mine gas 36 

sanitation 35 

Mosquitoes 15 

Mouth and teeth, care of 84 

Mumps 137 

complications in, treatment of 140 

transmission of 139 

treatment of 140 

Nasopharynx, cleansing of, in colds 102 

Nostrils and throat, care of 86 

Nutrition of schoolchildren 65 

Ophthalmia neonatorum 17 

Otorrhea 89 

Paralysis, diphtheritic 167 

in anterior poliomyelitis 231 

Paralysis, Infantile: see Poliomyelitis, Acute Anterior. 

Pediculosis 82 

Perspiration 80 

Pharyngitis, acute 104 

Poliomyelitis, acute anterior 222 

etiology of 223 

local treatment in 230 

pain in 229 

paralysis in 231 

prevention of 224 

symptoms of 225 

transmission of 227 

treatment of 226 

Pyorrhea 87 

Respiratory tract, diseases of 92 

Revaccination ^ 42 

Rotheln: See Measles, German. 
Rubella: See Measles, German. 

Rumpel-Leede diagnostic test in scarlet fever 192 



238 INDEX 

PAGE 

Salt water bathing 14 

Scarlet fever 188 

adenitis in 199 

albuminuria in 199 

blood in 197 

care of skin in 204 

care of throat and nose in 203 

complications of 198 

complications in, treatment of 206 

convalescence in 207 

diagnosis of 196 

diet in 201 

etiology of 189 

fever in 202 

heart in 205 

isolation in 200 

prevention of 191 

prevention of, in schools 193 

quarantine in 194 

Rumpel-Leede diagnostic test in 192 

symptoms of 195 

treatment of 200 

Scarlatina, surgfical 208 

Schick test m diphtheria 149 

School, hours in . , 54 

hygiene 6 

Schoolchildren, adenitis in 90 

adenoids in 88 

contagious skin diseases in 81 

effect of alcohol on 67 

effect of tobacco on , . 67 

eyes of 65 

home hygiene of 58 

hypertrophied tonsils in 88 

medical inspection of 62 

mental defect in 59 

nervous, care of 61 

nutrition of 65 

oral hygiene 84 

otorrhea in 89 

outdoor exercise for 55 

pediculosis in 82 

personal hygiene of = 78 

physical examination and physical exercise 56 

pyorrhea in ., 87 

record cards of 57 

teaching of hygiene to 60 

vulvovaginitis in 83 

Schoolhouses 53 

Schoolroom, air of 68 

Schools, disinfection of 76 

dissemination of contagion in 70 

fumigation oi , 71 

prophylaxis of diphtheria in 153 

sanitary measures in 63 

scarlet fever in, prevention of 193 

Seasons, effect of, on health 23 

Skin, contagious diseases of, in schoolchildren 81 

hygiene of , 19 

Sleep 2 



INDEX 239 

PAGE 

Small-pox vaccination 41 

Spotted Fever: See Meningitis, Cerebrospinal Epidemic. 

Summer heat 25 

Teeth and mouth, care of 84 

diseased, danger from 87 

Throat and nostrils, care of 86 

septic sore 169 

Tobacco, effect of, on children 67 

Tonsils 17 

hypertrophied 88 

infected, diseases due to 18 

Tooth brush 85 

Tuberculosis, dissemination of . . . 71 

Typhoid carriers, treatment of 51 

causes of , 44 

dissemination of 71 

in armies 46 

incubation period in 47 

prevention of , 45 

vaccination 43 

vacciiiation, contra-indications 48 

vaccine, method of injection 49 

vaccine therapy 50 

Uncinariasis: See Hookworm Disease 

Vaccination against typhoid fever 43 

against small-pox 41 

Vaccine prevention and vaccine therapy 40 

Varicella: See Chicken-Pox 

Ventilation 9 

Vulvovaginitis , 83 

Water 4 

Weather and health 24 

Whooping-cough 124 

cause of 125 

complications in, treatment of 135 

diagnosis of 127 

hygiene and nutrition in 131 

paroxysms in, treatment of 134 

pathology of 128 

prevention of 130 

transmission of , 126 

treatment of 129 



m 



Ar 



